Epilepsia

BackgroundDistinguishing epilepsy from functional/dissociative seizures (FDS) is an ongoing diagnostic challenge. Misdiagnosis delays appropriate treatment and puts patients at significant risk. Quantitative analyses of clinical EEG offer a potential avenue for developing decision-support tools in the diagnosis of seizure disorders. Recent work using univariate features demonstrated that reliably identifying diagnostic traits in the presence of confounding factors remains challenging. However, diagnostic information might be available in multivariate features such as network-based measures. Using a well-controlled dataset, we run the first diagnostic accuracy study assessing the potential of multivariate resting-state EEG markers to directly discriminate between a diagnosis of epilepsy and one of FDS at the time when a diagnosis is suspected and prior to treatment initiation. MethodsThe dataset, previously examined in a published study, includes 148 age- and sex-matched individuals with suspected seizure disorders who were later diagnosed with non-lesional epilepsy (n=75) or FDS (n=73). Eyes-closed, resting-state EEG data used for the analyses were normal on visual inspection, and acquired while participants were medication-free. Functional network measures in the 6-9 Hz range were extracted and machine learning implemented to assess their predictive potential; different model configurations (including varying model types, dimensionality reduction methods, and approaches to enhance feature stability) were tested to identify the most promising approach for future translational implementations. ResultsNetwork measures derived from resting-state EEG discriminate between conditions at levels significantly above chance (maximum balanced accuracy: 67.5%). Their sensitivity to epilepsy (81.8%) is consistently higher than their sensitivity to FDS (53.3%). A systematic assessment of model choices indicates that improving the temporal stability of network features through epoch-wise averaging improves classification accuracy (62.6% to 67.5%). Multiple nonlinear model types succeed on the classification problem, with the three-best performing assigning a consistent diagnostic label to 77.5% of the individuals; however, model choice remains a strong determinant of overall classification accuracy. Dimensionality reduction did not provide a significant advantage in our models. ConclusionWe establish evidence for the clinical validity of selected network-based markers to discriminate between a diagnosis of non-lesional epilepsy and FDS prior to treatment initiation, highlighting the measures potential to support post-test probability estimation in the clinic. Our models, configured to optimise balanced accuracy, classified people with epilepsy more accurately than people with FDS, indicating that these measures are specific to epilepsy and should not be interpreted as markers of a positive diagnosis of FDS.

Background: The detection of subtle epileptogenic lesions such as focal cortical dysplasias (FCDs) is a clinical challenge in the management of drug-resistant focal epilepsy (DRFE). Ultra-high field (UHF) MRI offers increased signal-to-noise ratios and spatial resolution compared to 3Tesla (T) MRI and may improve diagnostic yield. Here, we present a 9.4T MRI cohort study of patients with DRFE. Methods: We recruited n=21 DRFE patients (with 3T-MRI findings: 2 positive, 3 equivocal, 16 negative) undergoing presurgical workup, and n=20 healthy controls for 9.4T MRI (0.8 mm isotropic MP2RAGE, slabs of 0.375 x 0.375 x 0.8 mm T2*-weighted GRE) and 3T MRI (MP2RAGE, FLAIR) acquisitions. Visual review for possible epileptogenic lesions was performed by clinical experts. For histopathologically confirmed FCD lesions, we extracted surface-based quantitative features (cortical thickness, qT1, FLAIR, T2*, and QSM values) across cortical depths and distances from the lesion centre and performed high-resolution cortical profiling of 9.4T T2* values. Results: No new epileptogenic lesions were visually identified at 9.4T in 3T MRI negative patients. In the two patients with histopathologically confirmed lesions, the FCD IIb lesions were visible with distinct qualitative and quantitative features at both field strengths. One of these FCD IIb showed a focal cortical T2* reduction at 9.4T that could here be quantified via automated cortical profiling, consistent with the previously described "black line sign". Conclusion: 9.4T MRI findings in epileptogenic lesions underlying DRFE are consistent with those on 3T MRI. While additional lesions were not identified in patients with negative 3T MRI, higher resolution T2*-weighted sequences can reveal a feature not seen at 3T: Cortical profiling of FCDs highlights the black line sign and can possibly help refine surgical or ablation targeting for some FCDs. Further optimization of UHF protocols and analysis methods on larger cohorts may reveal clinically applicable diagnostic benefits.

1.PurposeSYNGAP1-related developmental and epileptic encephalopathy (SYNGAP1-DEE) is characterized by high rates of both epilepsy and autism spectrum disorder (ASD). While the clinical spectrum is well-documented, the link between specific seizure semiologies and caregiver-reported autistic behaviors is not well understood. This study analyzed the correlation between ten distinct seizure types, their frequencies, and a caregiver-reported autistic behavior score. MethodClinical data were extracted from the PATRE (PATient-based phenotyping and evaluation of therapy for Rare Epilepsies) Registry for SYNGAP1, in the framework of the EURAS project (Grant No. 101080580, Horizon Europe). This study employed a retrospective cross-sectional analysis of caregiver-reported registry data. Analysis was restricted to an analytic cohort of N=337 participants with complete data for both the epilepsy questionnaire (including epilepsy status, seizure semiology, and peak seizure frequency items) and the behavior questionnaire (from a total N=522 registry participants). Caregiver-reported autistic behaviors were quantified using a standardized caregiver-reported scale (Likert 1-5). Statistical associations were evaluated using the Wilcoxon rank-sum test to compare caregiver-reported autistic behavior scores across different seizure semiologies and Spearmans rank correlation to assess the impact of seizure frequency (9-point scale). ResultsWithin the analytic cohort (N=337), epilepsy was reported in 259 patients. Eyelid myoclonia was the most prevalent semiology, affecting 64.9% (n=168) of the epilepsy-positive group. Atypical absences (n=77) demonstrated the most profound and statistically robust association with higher caregiver-reported autistic behavior scores (FDR-adjusted p = 0.001). Significant associations were also observed for typical absences (n=70, FDR-adjusted p = 0.018), eyelid myoclonia (FDR-adjusted p = 0.018), myoclonic-atonic seizures (n=40, FDR-adjusted p = 0.019), and atonic seizures (n=72, FDR-adjusted p = 0.025). Focal and tonic-clonic seizures showed weaker associations (FDR-adjusted p = 0.026 and p = 0.047, respectively). Crucially, quantitative analysis revealed no significant correlation between ordinal caregiver-reported peak seizure frequency ratings and caregiver-reported autistic behavior scores across all semiologies (e.g., Eyelid Myoclonia: p=0.096; Atypical Absences: p=0.744), indicating no detectable association between peak-frequency ratings and caregiver-reported autistic behavior scores. ConclusionHigher caregiver-reported autistic behavior scores in SYNGAP1-DEE were most strongly associated with the presence of atypical absences, representing a generalized, thalamocortical seizure network dysfunction. In contrast, no detectable association was observed between caregiver-reported autistic behavior scores and the ordinal caregiver-reported peak seizure frequency metric. Atypical absences and related semiologies may serve as clinical "red flags" for increased neurodevelopmental comorbidity severity, regardless of reported peak seizure frequency. Abstract SummaryThis study investigates the relationship between ten seizure semiologies, seizure frequency, and severity of caregiver-reported autistic behaviors in a large-scale international cohort of N=337 patients with SYNGAP1-DEE. We identify a robust association between elevated caregiverreported autistic behavior scores and specific thalamocortical seizure patterns, most prominently atypical absences. Notably, our analysis reveals that this association is independent of seizure frequency, demonstrating no detectable association between this ordinal, caregiver-reported seizure frequency metric and caregiver-reported autistic behaviors.

Objective: Electrical brain stimulations (EBS) are central to epileptic network identification and functional mapping during stereo-electroencephalography (SEEG), yet stimulation frequencies remain empirical, and standardized across patients and brain regions, producing false negatives and false positives, and potentially compromising surgical outcome. We investigated theta-range EBS (7 Hz) in the temporal lobe, a prominent physiological frequency band in this region, and compared it with conventional 1-Hz and 50-Hz protocols. Methods: We analyzed 1,408 temporal EBS in 25 patients with drug-resistant epilepsy. Epileptic responses (afterdischarges, seizures) and clinical signs were assessed across the epileptic network and temporal structures (amygdala, hippocampus, neocortex, parahippocampal gyrus, white matter), and analyzed according to stimulation parameters (frequency, intensity, duration, total charge). Results: At matched intensity and duration, 7-Hz EBS were associated with a higher occurrence of afterdischarges and clinical signs than 1-Hz EBS in several temporal structures (e.g., parahippocampal epileptogenic zone: p=0.014). Effects on usual seizure induction were less consistent. Comparisons with 50 Hz showed no systematic significant differences, with responses observed at one or both frequencies depending on structure and outcome. When controlling for total charge, frequency-related differences were attenuated. Some effects were sporadically observed at both intermediate frequency and charge quantity. No adverse events occured. Significance: Theta-range stimulation modulates electrophysiological and clinical responses during SEEG mapping and may provide complementary information to conventional frequencies. These findings support exploring a broader range of stimulation frequencies, rather than relying solely on standard protocols.

ObjectiveIn individuals with drug-resistant epilepsy, accurately identifying the brain regions where seizures originate is a critical prerequisite to guide surgical treatment and achieve seizure freedom. To accomplish this, intracranial EEG is considered the gold standard, providing the spatiotemporal high-resolution data necessary to pinpoint epileptogenic activity. However, this precision is achieved through an invasive procedure with significant patient burden, which is fundamentally limited by the electrode placement and spatial coverage. MethodsIn this study, we investigated the potential utility of preoperative resting-state fMRI to non-invasively map alterations in brain dynamics at the whole brain level. Region-wise brain dynamics were quantified with complementary measures of local autocorrelation decay rates. We assessed the capacity of these derived features to effectively identify intracranial EEG confirmed seizure onset zones in 18 individuals with drug-resistant medial temporal lobe epilepsy. Overall, the study cohort contained 3867 implanted electrodes of which 159 classified as seizure onset zones by two independent board-certified epileptologists. ResultsOverall, our findings reveal more constrained temporal dynamics for brain regions associated with seizure onsets compared to non-seizure onset zones. Individual-level prediction showed a performance better than chance in 15 of the 18 patients. The overall predictive performance across all patients yielded a median AUC of 0.81, a median true positive rate of 0.75, and a median true negative rate of 0.83. Furthermore, in a subset of 13 patients, those with negative seizure outcomes showed higher probabilities of seizure onset zone predictions outside the resection area compared to those with good outcomes. SignificanceOverall, our findings suggest that altered temporal dynamics derived from preoperative resting-state fMRI represent a promising non-invasive approach for delineating epileptogenic tissue, potentially informing intervention strategies and guiding electrode placement.

Purpose: DNM1-related disorder is a rare developmental and epileptic encephalopathy. The current understanding of the clinical spectrum is based on sparse patient descriptions. Here, we compile the largest DNM1 cohort to date, to characterize the genotypic and phenotypic landscape of the disorder. Methods: Phenotypic data was manually curated from 95 individuals from multiple sources and harmonized using the Human Phenotype Ontology framework. Results: Disease-causing variants in DNM1 cluster in mutational hotspots within the gene, which achieve Strong and Moderate evidence for pathogenicity based on ACMG guidelines. The overall DNM1 phenotype was homogeneous compared to other genetic epilepsy conditions: SCN2A, SCN8A, STXBP1, and SYNGAP1. The p.R237W (n=15) variant was associated with bilateral tonic-clonic seizures, infantile spasms, and dystonia. The p.I398_R399insCR (n=14) variant was associated with severe hypotonia, profound global delay, and cortical visual impairment. Five individuals with homozygous loss-of-function variants were clinically similar to dominant-negative DNM1-related disorder, but microcephaly and brain MRI abnormalities were more common in this group. Conclusion: A harmonized cohort of individuals with DNM1-related disorder was analyzed to define mutational hotspots and reveal novel genotype-phenotype correlations. Due to the homogeneous phenotype, disease mechanism, and high proportion of recurrent variants, DNM1 represents an attractive target for targeted therapy development.

ObjectiveVagus nerve stimulation (VNS) is an established neuromodulation therapy used in the management of drug-resistant epilepsy (DRE), or when other intracranial surgical modalities have not reduced seizure burden. We evaluated whether prior intracranial surgery for epilepsy influences safety and effectiveness outcomes with adjunctive VNS, using real-world data from the CORE-VNS study. MethodsCORE-VNS (NCT03529045), a prospective, multicenter, international observational study, was designed to collect data on seizure and non-seizure outcomes in patients with DRE treated with VNS. Participants were identified as having or not having undergone prior intracranial brain surgery for epilepsy (ICSE) and received an initial VNS implant. Baseline seizure frequency data and patient-reported outcome measures were collected at 3, 6, 12, 24, and 36 months. This analysis compared the baseline data for VNS therapy and safety outcomes at 36 months. ResultsAmong 531 participants implanted with VNS, prior ICSE was performed in 84. Median percentage seizure reductions at 36 months for all seizures (76.6% and 76.3%), all focal seizures (83.3% and 71.8%), and all generalized seizures (77.8% and 76.2%) were found to be similar between those without and with a history of ICSE, respectively. The 50% responder rate for all seizures reported at baseline was similar, 64.8% and 61.8%, in both groups and complete seizure freedom was reported by 17.9% and 8.8%, respectively. Implant-related adverse events (AE) and serious AE rates were similar between groups. ConclusionVNS was associated with clinically meaningful seizure reductions and showed a consistent safety profile irrespective of the history of ICSE. Prior ICSE should not be a contraindication to the consideration of VNS.

Background and Purpose: 2-[18F] fluoro-2-deoxy-D-glucose positron emission tomography (static PET) has mixed specificity and sensitivity in targeting epileptic zones in the noninvasive stage of epilepsy surgery evaluations. We compared the signal quality of static PET compared to a method of interictal dynamic PET (iD-PET). Materials and Methods: We calculated the signal quality of static PET and iD-PET obtained from a cohort of patients with focal epilepsy. We developed a Bayesian regional estimated signal quality (BRESQ) technique to objectively compare signal-to-noise ratios (SNRs) by region of interest (ROI) within subjects. Results: Adjusted for ROI size and neighboring regions, iDPET was superior to sPET with probability >95% in 8/36 regions; >90% in 21/36 regions; >80% in 29/36 regions. The top five regions with the largest adjusted SNR differences (greatest magnitude of iDPET superiority) were the Temporal Mesial (Left and Right), Occipital Lateral (Left and Right), and the Left Frontal Inferior Base. Conclusions: We found that iDPET yielded a superior SNR in most ROI. BRESQ offers a scalable and generalizable method to quantify signal quality between brain mapping modalities.

YWHAG Syndrome (Developmental and Epileptic Encephalopathy 56, DEE56) is an ultra- rare childhood epilepsy associated with neurodevelopmental delays, with no therapeutic intervention available. Multiple de novo mutations in the YWHAG gene, encoding for the 14-3-3{gamma} protein, have been identified as causative for YWHAG Syndrome. 14-3-3{gamma} interacts with various targets, including major neurodevelopmental signaling proteins such as components of the ROCK pathway. Despite substantial evidence of the essential role of 14-3-3{gamma} in neurite outgrowth, cytoskeletal rearrangements, and neuronal migration during cortical development, little is known regarding the molecular consequences of YWHAG mutations and their effect on neuronal function and survival. Here, we characterized an isogenic, pluripotent stem cell (iPSC) model of YWHAGR132C/+ cortical neurons. The YWHAGR132C/+iPSC-derived neurons exhibited early cytoskeletal phenotypes, coupled with an elevated calcium baseline, lower frequency of calcium spikes, and reduced network activity. The widespread alterations in the transcriptome of mutant neurons revealed a biphasic dysregulation in the core genes and modulators associated with the ROCK pathway that resulted in maturation-dependent changes to cytoskeletal protein stability and calcium phenotypes. Direct inhibition of ROCK with Y27632 further increased the calcium baseline compared to the isogenic control. Exposure of YWHAGR132C/+ neurons to Trypsin-EDTA revealed underlying cytoskeletal instability, which was partially reversed by lovastatin treatment. Further, lovastatin partially rescued the elevated calcium baseline, but not the frequency or amplitude of calcium spikes. Together, these results suggest decoupling of calcium homeostasis and calcium signaling associated with cytoskeletal instability in YWHAGR132C/+ neurons. These findings lay the groundwork for future mechanistic studies of YWHAG function and molecular therapeutic targets for YWHAG Syndrome and YWHAG-associated conditions.

ImportanceEpilepsy is one of the most common neurological disorders globally. A significant proportion of patients fail to achieve effective seizure control with medication and ultimately develop drug-resistant epilepsy, particularly mesial temporal lobe epilepsy (MTLE). While surgical resection and laser interstitial thermal therapy (LITT) are effective treatments for drug-resistant MTLE, these procedures may be associated with severe adverse events. In contrast, allogeneic induced pluripotent stem cell (iPSC)-based therapy is expected to offer a novel, potentially safer therapeutic approach with fewer side effects for patients with drug-resistant MTLE. ObjectiveTo evaluate the safety and preliminary efficacy of a single intracranial injection of ALC05 (iPSC-derived GABAergic interneurons) in patients with unilateral MTLE, and to assess the therapeutic effects of different dosage levels. Design, Setting, and ParticipantsThis single-center, randomized, double-blind, Phase 1 clinical trial will enroll 12 subjects with unilateral MTLE. All subjects will be randomly assigned to either the low-dose or high-dose group in a 1:1 ratio. To minimize risks at each dose level, the first subject in each dose group will be monitored for safety for at least 3 months following ALC05 injection and must demonstrate acceptable safety and tolerability before the remaining subjects are enrolled. The primary outcome will be the incidence and severity of adverse events (AEs) and serious adverse events (SAEs). Secondary outcomes include cell engraftment and survival, responder rate, and seizure frequency. The follow-up period for this study is 1 year. After completing the follow-up period within this study, subjects will enter a 15-year long-term safety follow-up. DiscussionMTLE remains a significant challenge in neurology. The results of this study will provide critical data regarding the feasibility and preliminary efficacy of ALC05 in treating MTLE and may offer a transformative therapeutic option for this condition.

Polyhydramnios, Megalencephaly, and Symptomatic Epilepsy syndrome (PMSE/STRADA-related disorder) is a rare neurodevelopmental disorder characterized by megalencephaly (ME), early-onset drug-resistant epilepsy, neurocognitive impairment, and high early mortality, often due to status epilepticus. PMSE is caused by a multi-exon deletion in STRADA, encoding STRADA, which regulates the mechanistic target of rapamycin (mTOR) pathway. GABAergic inhibitory interneurons (INs) critically modulate the excitatory:inhibitory balance in cortical and hippocampal networks, and IN deficits contribute to epileptogenesis in several epileptic encephalopathies. However, no studies have investigated INs in PMSE. We used a multimodal approach to study INs in a Strada-/- mouse model engineered with the same causative 5-exon deletion identified in human PMSE. We demonstrate that Strada/STRADA loss causes a reduction of INs in the somatosensory cortex and a corresponding increase in the striatum, representative of remnant ganglionic eminence progenitor origin, in Strada-/- mice and a single PMSE brain tissue specimen. RNA sequencing comparing wildtype to Strada-/- cortex and striatum corroborated these findings, revealing increased IN-related gene expression (e.g., Dlx2) in the striatum and decreased IN-related gene expression (e.g., Pvalb) in the developing cortex. Cytoskeletal (e.g., Tpp3, Kank4, Map1a) and mTOR-associated genes (e.g., Rictor, Cryab) are differentially expressed in the developing cortex, mature striatum, and mature cortex of Strada-/- mice. Functional validation confirmed enlarged INs in mouse and human Strada/STRADA-deficient brain and enhanced S6 phosphorylation in Strada-/- striatum. Together, these findings suggest STRADA/Strada loss contributes to failed IN migration -- the first such report in a developmental, mTOR-associated megalencephaly syndrome -- highlighting INs as a therapeutic target for seizure prevention in PMSE. Key PointsO_LI- Reduced numbers of cortical inhibitory interneurons were observed in the cerebral cortex of Strada-/- mice, with striatal interneuron aggregation C_LIO_LI- Reduced numbers of cortical inhibitory interneurons, with an aggregation in striatum, were observed in human PMSE brain, supporting the observations in Strada-/- mouse C_LIO_LI- Transcriptomic analysis in Strada-/- mice reveals evidence of early developmental interneuron and cytoskeletal dysfunction C_LIO_LI- We introduce a loss of cortical interneurons as a salient feature of PMSE developmental pathogenesis, potentially contributing to a loss of inhibitory modulation C_LIO_LI- This is the first study proposing interneuron migration impairment in the developmental pathogenesis of an mTOR-associated megalencephaly syndrome C_LI

Focal cortical dysplasias (FCDs) are one of the most common structural causes of drug-resistant epilepsy in children but are frequently subtle and difficult to detect on conventional MRI. Many automated lesion detection methods have therefore been proposed to support neuroradiological assessment. In this study, we externally validated two recently developed deep-learning approaches for FCD detection, MELD Graph and 3D-nnUNet, in a pediatric cohort. In this retrospective single-center study, brain MRI scans of 71 children evaluated for epilepsy were analyzed, including 35 MRI-positive patients with suspected FCD and 36 MRI-negative cases based on the primary radiology reports. Both models were applied to standard 3D T1-weighted and 3D FLAIR images. Detected lesions were reviewed by an experienced pediatric neuroradiologist and classified as true positive, false positive, or false negative. Clinical semiology and EEG findings were additionally evaluated for cases with false-positive detections. At the lesion level, MELD Graph achieved a precision of 0.85 and recall of 0.52, while 3D-nnUNet achieved a precision of 0.91 and recall of 0.48. In the MRI-negative patients, MELD Graph produced more false-positive detections than 3D-nnUNet (0.53 vs. 0.14 false-positive lesions per patient). At the patient level, MELD Graph showed slightly higher sensitivity than 3D-nnUNet (0.63 vs. 0.54), whereas 3D-nnUNet demonstrated markedly higher specificity (0.86 vs. 0.56). Improved FLAIR image quality was associated with trends toward improved model performance. Both models demonstrated high precision but moderate sensitivity, indicating that they are valuable decision-support tools but cannot replace expert neuroradiological evaluation. Optimized MRI acquisition protocols are needed to further improve automated lesion detection in pediatric epilepsy.

Cognitive difficulties are increasingly recognized in juvenile myoclonic epilepsy (JME), but scalable biomarkers linking resting-state brain dynamics to general mental ability remain limited. Here, we combined topological data analysis, graph signal processing, machine learning, inverse Langevin modeling, and biophysical simulations to test whether EEG-derived network dynamics capture individual differences in general mental ability in JME. We studied 54 patients with JME and 45 healthy controls using resting-state high-density EEG and the raw estimated full-scale score derived from the Wechsler Abbreviated Scale of Intelligence (WASI), used here as an index of general mental ability. Subject-specific low-alpha activity was reconstructed with generalized eigendecomposition, and graph-derived features were extracted from the projection of topological and alpha-power signals onto the functional connectome, providing a graph-harmonic description of large-scale brain-state dynamics. In controls, dynamic EEG-derived features significantly predicted general mental ability, whereas the same framework failed in JME. Because prediction in controls was driven mainly by dynamic measures of smoothness (Dirichlet energy), we next examined the temporal organization of alpha-power smoothness using an inverse Langevin framework. Within the patient group, greater thermodynamic rigidity--that is, stronger confinement of fluctuations around preferred network states--was associated with lower general mental ability. Relative to controls, patients also showed lower thermodynamic noise, indicating a reduced tendency to explore alternative network regimes. Biophysical simulations suggested that reduced dendritic arborization can generate rigidity directly, whereas pharmacological stabilization of hyperexcitable circuits can shift the system toward a more rigid, lower-noise regime. Together, these findings suggest that cognition in JME is linked not only to altered resting-state network dynamics but also to stronger confinement of network-state fluctuations, with both intrinsic circuit abnormalities and treatment-related stabilization representing plausible routes to this rigid phenotype.

BackgroundPhelan McDermid syndrome (PMS), caused by SHANK3 haploinsufficiency, is a genetic form of autism spectrum disorder (ASD) that provides a genetically defined model for studying ASD-related circuit dysfunction. SHANK3 mutations disrupt synaptic organization and cortical synchrony, leading to attenuated gamma-band auditory steady-state responses (ASSRs). We investigated whether PMS-related electrophysiological signatures could be identified using machine learning and whether similar patterns are present in a subset of individuals with idiopathic ASD (iASD). MethodsEEG recorded during a 40-Hz ASSR paradigm was collected from 123 participants (42 TD aged 2-30, 56 iASD aged 3-31, 25 PMS aged 2-26). We extracted time-series, ERSP, FOOOF-derived spectral, and intertrial phase coherence (ITPC) features. XGBoost models with leave-one-out cross-validation classified PMS versus TD; the best age/sex-adjusted ITPC model was then applied to iASD participants to derive a Synchrony Atypicality Index (SAI). Unsupervised clustering of high-dimensional ITPC features was also performed. ResultsITPC-based models showed the strongest discrimination between TD and PMS participants (AUROC = 0.83). When applied to iASD participants, 35.7% exhibited elevated SAI, indicating a PMS-like gamma-band phase-locking profile. Classification of iASD versus PMS performed poorly in the full sample but improved markedly after excluding high-SAI iASD individuals, consistent with substantial heterogeneity within iASD. Unsupervised clustering of ITPC features identified PMS-enriched clusters that also captured high-SAI iASD participants. Results were consistent after controlling for age in sensitivity analyses. ConclusionsReduced 40-Hz ITPC is a mechanistically interpretable electrophysiological signature of PMS and identifies a biologically meaningful PMS-like subgroup within iASD, supporting biomarker-guided stratification.

Genetic deletion or pharmacological blockade of P2X7 receptors (Rs) counteract status epilepticus (SE) in animal models of epilepsy. It is, however, unclear whether P2X7Rs are localized at astrocytes or neurons, and the reason for astrocytic atrophy arising in consequence of SE is also ambiguous. We conducted a combined morphological/electrophysiological study in order to investigate these issues. It has been shown that kainic acid (KA)-induced SE in mice led to the atrophy of hippocampal astrocytes and at the same time to the decrease of ezrin immunoreactivity and its co-expression with mCherry, whose synthesis has been initiated by the injection of a virus complex. mCherry expression in astrocytes enabled us to study changes in cell somata and processes brought about by KA-injection. Ezrin is a plasmalemmal-cytoskeleton linker; its grade of expression indicates changes in the existence/function of small peripheral astrocytic processes. Pretreatment of mice with the blood-brain barrier-permeable P2X7R antagonist JNJ-47965567 prevented the SE-induced damage of astrocytes. KA caused a potentiation of dibenzoyl-ATP (Bz-ATP) currents in astrocytes but not neurons of the hippocampus. This effect was also abolished by pre-treatment of mice with JNJ-47965567 before applying KA, although no similar changes occurred in hippocampal CA1 neurons. The measurement of spontaneous postsynaptic currents (sPSCs) and spontaneous excitatory postsynaptic currents (sEPSCs) indicated a presynaptic facilitation of neurotransmitter release by Bz-ATP. In conclusion, we suggest that astrocytic P2X7Rs are the primary target of ATP release from damaged CNS cells in the hippocampus which simultaneously causes damage to astrocytic somata and processes.

Hippocampal sclerosis is a frequent finding in pediatric epilepsy surgery and has traditionally been regarded as an acquired lesion. It commonly co-occurs with focal cortical dysplasia (FCD IIIa), yet whether hippocampal injury is secondary to seizures or reflects a shared underlying etiology remains unresolved. Here we identified somatic variants activating the RAS-MAPK pathway in 40% of patients with hippocampal sclerosis, but in none with non-sclerotic hippocampus. Gain-of-function variants in PTPN11 were the most common finding, with mutations present in both cortex and hippocampus and enriched in hippocampal neurons, consistent with a shared developmental origin. In mice, Ptpn11D61Y mutants developed profound hippocampal degeneration and gliosis following subthreshold kainic acid exposure, whereas wild-type controls were unaffected. p38-dependent stress pathways were upregulated in patients and mice, suggesting a mechanism through which ERK-p38 crosstalk lowers the threshold for seizure-induced injury. These results provide a genetic explanation for FCD IIIa, elucidate the role of somatic mutations within the RAS-MAPK pathway in driving hippocampal sclerosis, and provide a target for pathway-specific interventions for intractable seizures.

The non-euphorigenic phytocannabinoid cannabidiol (CBD) has demonstrated therapeutic efficacy in childhood-onset epilepsies. Using a songbird preclinical model we have found that CBD promotes recovery of learned vocalizations following focal motor cortical injury. But questions about cellular mechanisms supporting this protection remained. Songbird vocal learning, like human speech, depends on development and maintenance of specialized neural circuits. Partial lesioning (microlesions) of the vocal pre-motor cortical-like song region HVC transiently disrupts song structure and triggers injury-associated cellular stress responses across interconnected song regions. Building on prior findings that CBD reduces neuroinflammation and synaptic loss in zebra finch song circuitry, we investigated potential astrocyte contributions. Here we report that HVC microlesions induce significant cell loss in HVC and its projection targets (vocal motor RA and striatal Area X), with a substantial fraction of apoptotic cells being astrocytes. CBD treatment reduces lesion-induced apoptosis and preserves astrocyte populations, indicating enhanced astrocyte viability as a major factor in CBD-mediated neuroprotection. Microlesions also elevate astrocyte stress, including increased lysosomal burden (LAMP1/LC3 expression) and astrocytic reactivity markers (C3, S100A10, aromatase). CBD attenuates these stress responses while enhancing neuroprotective metabolic and antioxidant mediators (glutamine synthetase [GS], glutamate-cysteine ligase modifier subunit [GCLM]), consistent with improved antioxidant and excitotoxicity resistance. Given that development-dependent sensorimotor skills (e.g. song in songbirds, language and many others in humans) depend on sensitive period establishment and ongoing post-learning maintenance of specialized neural circuits vulnerable to traumatic disruption, the zebra finch model provides a valuable preclinical platform for investigating glial-targeted interventions to promote circuit resilience and functional recovery after TBI.

Importance: NGLY1 (N-Glycanase 1) Deficiency is an ultra-rare autosomal recessive disorder affecting ~165 patients worldwide, characterized by developmental delay, hyperkinetic movement disorders, and shortened life expectancy. Despite its severe neurological manifestations, comprehensive neuroimaging characterization has been limited to case reports and small descriptive studies. Objective: To investigate alterations in brain morphology in patients with NGLY1 Deficiency and determine whether these metrics associate with clinical phenotypes. Design, Setting, and Participants: This case series analyzed real-world MRI scans performed on 11 patients with NGLY1 Deficiency between 1999-2023 at sites across the globe. Ages ranged from 2 to 19 years at scan time (5 female, 6 male). Exposure: Molecular diagnosis of NGLY1 Deficiency. Main Outcomes and Measures: Cortical and subcortical morphology, including subcortical volume, and cortical thickness, surface area, volume, and curvature, were measured with 3-dimensional T1-weighted magnetic resonance imaging (MRI) scans. Z-scores were calculated using normative models from CentileBrain for patients >3 years old or custom models for patients <3 years old. Clinical phenotypes were matched to Human Phenotype Ontology codes. Results: 16 scans from 11 patients met quality criteria for analysis. Both age groups (under and over 3 years old) showed significantly reduced subcortical volumes, particularly in bilateral thalamus and putamen. Younger patients demonstrated widespread reductions in cortical surface area, volume, and curvature, indicating altered gyrification patterns. Older patients showed thinner dorsal and thicker ventral cortical regions with limited surface area reductions. Thalamic volume reduction in older patients correlated with gait disturbance, dysphagia, and EEG abnormalities, with additional cortical associations with sleep and hearing abnormalities. Seizure presence in younger patients correlated with altered cortical thickness, surface area, and curvature patterns. Conclusions and Relevance: NGLY1 Deficiency is associated with pervasive alterations in brain development affecting both subcortical and cortical morphology. Age-dependent patterns of cortical alterations indicate disrupted neurodevelopmental trajectories that may reflect impaired neuronal migration and/or altered synaptic pruning. Correlations with clinical variables suggest that these measures may serve as useful biomarkers for tracking disease progression and/or treatment efficacy. These findings provide a comprehensive neuroimaging characterization of NGLY1 Deficiency and establish a foundation for understanding brain structure-function relationships in this ultra-rare disorder.

To date, FBRSL1-related disorder has been reported in five individuals with congenital abnormalities and severe postnatal impairment with or without epilepsy; however, the full extent of the phenotypic and genotypic spectrum remains unclear. Previously reported cases involved small truncating variants apparently escaping nonsense-mediated decay, suggesting either a haploinsufficiency or a dominant-negative mechanism. We report the first case of a complex structural variant at the FBRSL1 locus, resulting in an additional, partially truncated copy of the gene, providing strong evidence for a dominant-negative mechanism. RNA-Seq supported the expression of the additional truncated gene copy. The patient is an infant girl with a profound developmental and epileptic encephalopathy (DEE). The child presented at birth with intrauterine growth restriction, respiratory insufficiency, severe swallowing dysfunction, spasticity, contractures, optic nerve hypoplasia, facial dysmorphism, and atrial septal defect. She developed severe postnatal growth restriction with microcephaly and profound developmental impairment. She has a DEE with frequent neonatal focal seizures evolving to infantile epileptic spasms syndrome (IESS). Our patient has congenital abnormalities in common with previously reported cases, along with a profound DEE, not associated previously with FBRSL1. Our case expands both the phenotypic and genotypic spectrum of FBRSL1-related disorder.

Rhodopsin (RHO) P23H is one of the most common mutations causing autosomal dominant retinitis pigmentosa (adRP), yet the relationship between retinal electrophysiology, structure and visually guided behaviour in rodent models remains unclear. We characterised changes in heterozygous P23H (Sakami line) mice and P23H line 3 (P23H-3) rats using full-field electroretinography (ERG), optomotor response (OMR) assays and, in rats, optical coherence tomography (OCT). ERG assessed rod- and cone-mediated responses relative to wild-type controls, whereas OMR under scotopic and photopic conditions quantified contrast sensitivity and visual acuity. In P23H mice, scotopic ERG responses were significantly reduced from postnatal day 16 and declined further from 4 months. Scotopic OMR contrast sensitivity remained largely preserved until 2 months, and photopic acuity was comparable to wild-type up to 6 months. In 13-week-old P23H-3 rats, ERG amplitudes were significantly reduced, and OCT revealed retinal thinning. OMR showed a decline in contrast sensitivity at 7 and 15 weeks, whereas photopic acuity was maintained. Thus, in both models, electrophysiological and structural abnormalities precede detectable OMR deficits, with implications for the selection of outcome measures in preclinical studies. Summary StatementThis study compares electrical and behavioural measures of vision in rodent models of inherited blindness, revealing that retinal dysfunction appears well before measurable vision loss.