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Sunday, November 18, 2018

Anticonvulsant

From Wikipedia, the free encyclopedia

Anticonvulsant
Drug class
Class identifiers
SynonymsAntiepileptic drugs, antiseizure drugs
UseEpilepsy
Biological targetBrain

Anticonvulsants (also commonly known as antiepileptic drugs or as antiseizure drugs) are a diverse group of pharmacological agents used in the treatment of epileptic seizures. Anticonvulsants are also increasingly being used in the treatment of bipolar disorder and borderline personality disorder, since many seem to act as mood stabilizers, and for the treatment of neuropathic pain. Anticonvulsants suppress the excessive rapid firing of neurons during seizures. Anticonvulsants also prevent the spread of the seizure within the brain.

Conventional antiepileptic drugs may block sodium channels or enhance γ-aminobutyric acid (GABA) function. Several antiepileptic drugs have multiple or uncertain mechanisms of action. Next to the voltage-gated sodium channels and components of the GABA system, their targets include GABAA receptors, the GAT-1 GABA transporter, and GABA transaminase. Additional targets include voltage-gated calcium channels, SV2A, and α2δ. By blocking sodium or calcium channels, antiepileptic drugs reduce the release of excitatory glutamate, whose release is considered to be elevated in epilepsy, but also that of GABA. This is probably a side effect or even the actual mechanism of action for some antiepileptic drugs, since GABA can itself, directly or indirectly, act proconvulsively. Another potential target of antiepileptic drugs is the peroxisome proliferator-activated receptor alpha. The drug class was the 5th-best-selling in the US in 2007.

Some anticonvulsants have shown antiepileptogenic effects in animal models of epilepsy. That is, they either prevent the development of epilepsy or can halt or reverse the progression of epilepsy. However, no drug has been shown in human trials to prevent epileptogenesis (the development of epilepsy in an individual at risk, such as after a head injury).

Terminology

Anticonvulsants are more accurately called antiepileptic drugs (abbreviated "AEDs"), and are often referred to as antiseizure drugs because they provide symptomatic treatment only and have not been demonstrated to alter the course of epilepsy.

Approval

The usual method of achieving approval for a drug is to show it is effective when compared against placebo, or that it is more effective than an existing drug. In monotherapy (where only one drug is taken) it is considered unethical by most to conduct a trial with placebo on a new drug of uncertain efficacy. This is because untreated epilepsy leaves the patient at significant risk of death. Therefore, almost all new epilepsy drugs are initially approved only as adjunctive (add-on) therapies. Patients whose epilepsy is currently uncontrolled by their medication (i.e., it is refractory to treatment) are selected to see if supplementing the medication with the new drug leads to an improvement in seizure control. Any reduction in the frequency of seizures is compared against a placebo. The lack of superiority over existing treatment, combined with lacking placebo-controlled trials, means that few modern drugs have earned FDA approval as initial monotherapy. In contrast, Europe only requires equivalence to existing treatments, and has approved many more. Despite their lack of FDA approval, the American Academy of Neurology and the American Epilepsy Society still recommend a number of these new drugs as initial monotherapy.

Drugs

In the following list, the dates in parentheses are the earliest approved use of the drug.

Aldehydes

  • Paraldehyde (1882). One of the earliest anticonvulsants. It is still used to treat status epilepticus, particularly where there are no resuscitation facilities.

Aromatic allylic alcohols

Barbiturates

Barbiturates are drugs that act as central nervous system (CNS) depressants, and by virtue of this they produce a wide spectrum of effects, from mild sedation to anesthesia. The following are classified as anticonvulsants: Phenobarbital was the main anticonvulsant from 1912 until the development of phenytoin in 1938. Today, phenobarbital is rarely used to treat epilepsy in new patients since there are other effective drugs that are less sedating. Phenobarbital sodium injection can be used to stop acute convulsions or status epilepticus, but a benzodiazepine such as lorazepam, diazepam or midazolam is usually tried first. Other barbiturates only have an anticonvulsant effect at anaesthetic doses.

Benzodiazepines

The benzodiazepines are a class of drugs with hypnotic, anxiolytic, anticonvulsive, amnestic and muscle relaxant properties. Benzodiazepines act as a central nervous system depressant. The relative strength of each of these properties in any given benzodiazepine varies greatly and influences the indications for which it is prescribed. Long-term use can be problematic due to the development of tolerance to the anticonvulsant effects and dependency. Of the many drugs in this class, only a few are used to treat epilepsy: The following benzodiazepines are used to treat status epilepticus:
  • Diazepam (1963). Can be given rectally by trained care-givers.
  • Midazolam (N/A). Increasingly being used as an alternative to diazepam. This water-soluble drug is squirted into the side of the mouth but not swallowed. It is rapidly absorbed by the buccal mucosa.
  • Lorazepam (1972). Given by injection in hospital.
Nitrazepam, temazepam, and especially nimetazepam are powerful anticonvulsant agents, however their use is rare due to an increased incidence of side effects and strong sedative and motor-impairing properties.

Bromides

  • Potassium bromide (1857). The earliest effective treatment for epilepsy. There would not be a better drug until phenobarbital in 1912. It is still used as an anticonvulsant for dogs and cats.

Carbamates

  • Felbamate (1993). This effective anticonvulsant has had its usage severely restricted due to rare but life-threatening side effects.

Carboxamides

Carbamazepine

The following are carboxamides:
  • Carbamazepine (1963). A popular anticonvulsant that is available in generic formulations.
  • Oxcarbazepine (1990). A derivative of carbamazepine that has similar efficacy but is better tolerated and is also available generically.
  • Eslicarbazepine acetate (2009)

Fatty acids

The following are fatty-acids: Vigabatrin and progabide are also analogs of GABA.

Fructose derivatives

GABA analogs

Hydantoins

The following are hydantoins:

Oxazolidinediones

The following are oxazolidinediones:

Propionates

Pyrimidinediones

Pyrrolidines

Succinimides

The following are succinimides:

Sulfonamides

Triazines

Ureas

Valproylamides

Other

Non-pharmaceutical anticonvulsants

Sometimes, ketogenic diet or vagus nerve stimulation are described as "anticonvulsant" therapies as well. However they do not work as well as the anticonvulsant drugs

Treatment guidelines

According to guidelines by the American Academy of Neurology and American Epilepsy Society, mainly based on a major article review in 2004, patients with newly diagnosed epilepsy who require treatment can be initiated on standard anticonvulsants such as carbamazepine, phenytoin, valproic acid/valproate semisodium, phenobarbital, or on the newer anticonvulsants gabapentin, lamotrigine, oxcarbazepine or topiramate. The choice of anticonvulsants depends on individual patient characteristics. Both newer and older drugs are generally equally effective in new onset epilepsy. The newer drugs tend to have fewer side effects. For newly diagnosed partial or mixed seizures, there is evidence for using gabapentin, lamotrigine, oxcarbazepine or topiramate as monotherapy. Lamotrigine can be included in the options for children with newly diagnosed absence seizures.

History

The first anticonvulsant was bromide, suggested in 1857 by the British gynecologist Charles Locock who used it to treat women with "hysterical epilepsy" (probably catamenial epilepsy). Bromides are effective against epilepsy, and also cause impotence, which is not related to its anti-epileptic effects. Bromide also suffered from the way it affected behaviour, introducing the idea of the 'epileptic personality' which was actually a result of medication. Phenobarbital was first used in 1912 for both its sedative and antiepileptic properties. By the 1930s, the development of animal models in epilepsy research led to the development of phenytoin by Tracy Putnam and H. Houston Merritt, which had the distinct advantage of treating epileptic seizures with less sedation.[35] By the 1970s, a National Institutes of Health initiative, the Anticonvulsant Screening Program, headed by J. Kiffin Penry, served as a mechanism for drawing the interest and abilities of pharmaceutical companies in the development of new anticonvulsant medications.

Marketing approval history

The following table lists anticonvulsant drugs together with the date their marketing was approved in the US, UK and France. Data for the UK and France are incomplete. In recent years, the European Medicines Agency has approved drugs throughout the European Union. Some of the drugs are no longer marketed.

Drug Brand US UK France
acetazolamide Diamox 27 July 1953 1988
carbamazepine Tegretol 15 July 1974 1965 1963
clobazam Frisium
1979
clonazepam Klonopin/Rivotril 4 June 1975 1974
diazepam Valium 15 November 1963

divalproex sodium Depakote 10 March 1983

eslicarbazepine
Data needed

ethosuximide Zarontin 2 November 1960 1955 1962
ethotoin Peganone 22 April 1957

felbamate Felbatol 29 July 1993

fosphenytoin Cerebyx 5 August 1996

gabapentin Neurontin 30 December 1993 May 1993 October 1994
lamotrigine Lamictal 27 December 1994 October 1991 May 1995
lacosamide Vimpat 28 October 2008

levetiracetam Keppra 30 November 1999 29 September 2000 29 September 2000
mephenytoin Mesantoin 23 October 1946

metharbital Gemonil 1952

methsuximide Celontin 8 February 1957

methazolamide Neptazane 26 January 1959

oxcarbazepine Trileptal 14 January 2000 2000
phenobarbital

1912 1920
phenytoin Dilantin/Epanutin 1938 1938 1941
phensuximide Milontin 1953

pregabalin Lyrica 30 December 2004 6 July 2004 6 July 2004
primidone Mysoline 8 March 1954 1952 1953
sodium valproate Epilim
December 1977 June 1967
stiripentol Diacomit
5 December 2001 5 December 2001
tiagabine Gabitril 30 September 1997 1998 November 1997
topiramate Topamax 24 December 1996 1995
trimethadione Tridione 25 January 1946

valproic acid Depakene/Convulex 28 February 1978 1993
vigabatrin Sabril 21 August 2009 1989
zonisamide Zonegran 27 March 2000 10 March 2005 10 March 2005

Pregnancy

During pregnancy, the metabolism of several anticonvulsants is affected. There may be an increase in the clearance and resultant decrease in the blood concentration of lamotrigine, phenytoin, and to a lesser extent carbamazepine, and possibly decreases the level of levetiracetam and the active oxcarbazepine metabolite, the monohydroxy derivative. Therefore, these drugs should be monitored during use in pregnancy.

Many of the common used medications, such as valproate, phenytoin, carbamazepine, phenobarbitol, gabapentin have been reported to cause increased risk of birth defects. Among anticonvulsants, levetiracetam and lamotrigine seem to carry the lowest risk of causing birth defects. The risk of untreated epilepsy is believed to be greater than the risk of adverse effects caused by these medications, necessitating continuation of antiepileptic treatment.

Valproic acid, and its derivatives such as sodium valproate and divalproex sodium, causes cognitive deficit in the child, with an increased dose causing decreased intelligence quotient. On the other hand, evidence is conflicting for carbamazepine regarding any increased risk of congenital physical anomalies or neurodevelopmental disorders by intrauterine exposure. Similarly, children exposed lamotrigine or phenytoin in the womb do not seem to differ in their skills compared to those who were exposed to carbamazepine.

There is inadequate evidence to determine if newborns of women with epilepsy taking anticonvulsants have a substantially increased risk of hemorrhagic disease of the newborn.

Regarding breastfeeding, some anticonvulsants probably pass into breast milk in clinically significant amounts, including primidone and levetiracetam. On the other hand, valproate, phenobarbital, phenytoin, and carbamazepine probably are not transferred into breast milk in clinically important amounts.

In animal models, several anticonvulsant drugs have been demonstrated to induce neuronal apoptosis in the developing brain.

GABAA receptor

From Wikipedia, the free encyclopedia

Structure of the nicotinic acetylcholine receptor (nAchR: PDB: 2BG9​) which is very similar to the GABAA receptor. Top: side view of the nAchR embedded in a cell membrane. Bottom: view of the receptor from the extracellular face of the membrane. The subunits are labeled according to the GABAA nomenclature and the approximate locations of the GABA and benzodiazepine (BZ) binding sites are noted (between the α- and β-subunits and between the α- and γ-subunits respectively).

Schematic structure of the GABAA receptor. Left: GABAA monomeric subunit imbedded in a lipid bilayer (yellow lines connected to blue spheres). The four transmembrane α-helices (1–4) are depicted as cylinders. The disulfide bond in the N-terminal extracellular domain which is characteristic of the family of cys-loop receptors (which includes the GABAA receptor) is depicted as a yellow line. Right: Five subunits symmetrically arranged about the central chloride anion conduction pore. The extracellular loops are not depicted for the sake of clarity.

The GABAA receptor (GABAAR) is an ionotropic receptor and ligand-gated ion channel. Its endogenous ligand is γ-aminobutyric acid (GABA), the major inhibitory neurotransmitter in the central nervous system. Upon activation, the GABAA receptor selectively conducts Cl through its pore. Cl- will flow out of the cell if the internal voltage is less than resting potential and Cl- will flow in if it is more than resting potential (i.e. -75mV). This causes an inhibitory effect on neurotransmission by diminishing the chance of a successful action potential occurring. The reversal potential of the GABAA-mediated inhibitory postsynaptic potential (IPSP) in normal solution is −70 mV, contrasting the GABAB IPSP (-100mV).

The active site of the GABAA receptor is the binding site for GABA and several drugs such as muscimol, gaboxadol, and bicuculline. The protein also contains a number of different allosteric binding sites which modulate the activity of the receptor indirectly. These allosteric sites are the targets of various other drugs, including the benzodiazepines, nonbenzodiazepines, neuroactive steroids, barbiturates, alcohol (ethanol), inhaled anaesthetics, and picrotoxin, among others.
GABAA receptors occur in all organisms that have a nervous system. To a limited extent the receptors can be found in non-neuronal tissues. Due to their wide distribution within the nervous system of mammals they play a role in virtually all brain functions.

Target for benzodiazepines

The ionotropic GABAA receptor protein complex is also the molecular target of the benzodiazepine class of tranquilizer drugs. Benzodiazepines do not bind to the same receptor site on the protein complex as the endogenous ligand GABA (whose binding site is located between α- and β-subunits), but bind to distinct benzodiazepine binding sites situated at the interface between the α- and γ-subunits of α- and γ-subunit containing GABAA receptors. While the majority of GABAA receptors (those containing α1-, α2-, α3-, or α5-subunits) are benzodiazepine sensitive, there exists a minority of GABAA receptors (α4- or α6-subunit containing) which are insensitive to classical 1,4-benzodiazepines, but instead are sensitive to other classes of GABAergic drugs such as neurosteroids and alcohol. In addition peripheral benzodiazepine receptors exist which are not associated with GABAA receptors. As a result, the IUPHAR has recommended that the terms "BZ receptor", "GABA/BZ receptor" and "omega receptor" no longer be used and that the term "benzodiazepine receptor" be replaced with "benzodiazepine site".

In order for GABAA receptors to be sensitive to the action of benzodiazepines they need to contain an α and a γ subunit, between which the benzodiazepine binds. Once bound, the benzodiazepine locks the GABAA receptor into a conformation where the neurotransmitter GABA has much higher affinity for the GABAA receptor, increasing the frequency of opening of the associated chloride ion channel and hyperpolarising the membrane. This potentiates the inhibitory effect of the available GABA leading to sedative and anxiolytic effects.

Different benzodiazepines have different affinities for GABAA receptors made up of different collection of subunits, and this means that their pharmacological profile varies with subtype selectivity. For instance, benzodiazepine receptor ligands with high activity at the α1 and/or α5 tend to be more associated with sedation, ataxia and amnesia, whereas those with higher activity at GABAA receptors containing α2 and/or α3 subunits generally have greater anxiolytic activity. Anticonvulsant effects can be produced by agonists acting at any of the GABAA subtypes, but current research in this area is focused mainly on producing α2-selective agonists as anticonvulsants which lack the side effects of older drugs such as sedation and amnesia.

The binding site for benzodiazepines is distinct from the binding site for barbiturates and GABA on the GABAA receptor, and also produces different effects on binding, with the benzodiazepines causing bursts of chloride channel opening to occur more often, while the barbiturates cause the duration of bursts of chloride channel opening to become longer. Since these are separate modulatory effects, they can both take place at the same time, and so the combination of benzodiazepines with barbiturates is strongly synergistic, and can be dangerous if dosage is not strictly controlled.

Also note that some GABAA agonists such as muscimol and gaboxadol do bind to the same site on the GABAA receptor complex as GABA itself, and consequently produce effects which are similar but not identical to those of positive allosteric modulators like benzodiazepines.

Structure and function

Schematic diagram of a GABAA receptor protein ((α1)2(β2)2(γ2)) which illustrates the five combined subunits that form the protein, the chloride (Cl) ion channel pore, the two GABA active binding sites at the α1 and β2 interfaces, and the benzodiazepine (BDZ) allosteric binding site
 
Structural understanding of the GABAA receptor was initially based on homology models, obtained using crystal structures of homologous proteins like Acetylcholine binding protein (AChBP) and nicotinic acetylcholine (nACh) receptors as templates. The much sought structure of a GABAA receptor was finally resolved, with the disclosure of the crystal structure of human β3 homopentameric GABAA receptor. Whilst this was a major development, the majority of GABAA receptors are heteromeric and the structure did not provide any details of the benzodiazepine binding site. This was finally elucidated in 2018 by the publication of a high resolution cryo-EM structure of a human α1β2γ2 receptor bound with GABA and the neutral benzodiazepine flumazenil.

GABAA receptors are pentameric transmembrane receptors which consist of five subunits arranged around a central pore. Each subunit comprises four transmembrane domains with both the N- and C-terminus located extracellularly. The receptor sits in the membrane of its neuron, usually localized at a synapse, postsynaptically. However, some isoforms may be found extrasynaptically. The ligand GABA is the endogenous compound that causes this receptor to open; once bound to GABA, the protein receptor changes conformation within the membrane, opening the pore in order to allow chloride anions (Cl) to pass down an electrochemical gradient. Because the reversal potential for chloride in most neurons is close to or more negative than the resting membrane potential, activation of GABAA receptors tends to stabilize or hyperpolarise the resting potential, and can make it more difficult for excitatory neurotransmitters to depolarize the neuron and generate an action potential. The net effect is typically inhibitory, reducing the activity of the neuron. However, depolarizing responses have been found to occur in response to GABA in immature neurons due to a modified Cl- gradient. These depolarization events have shown to be key in neuronal development. In the mature neuron, the GABAA channel opens quickly and thus contributes to the early part of the inhibitory post-synaptic potential (IPSP). The endogenous ligand that binds to the benzodiazepine site is inosine.

Subunits

GABAA receptors are members of the large pentameric ligand gated ion channel (previously referred to as "Cys-loop" receptors) super-family of evolutionarily related and structurally similar ligand-gated ion channels that also includes nicotinic acetylcholine receptors, glycine receptors, and the 5HT3 receptor. There are numerous subunit isoforms for the GABAA receptor, which determine the receptor's agonist affinity, chance of opening, conductance, and other properties.

In humans, the units are as follows:
There are three ρ units (GABRR1, GABRR2, GABRR3); however, these do not coassemble with the classical GABAA units listed above, but rather homooligomerize to form GABAA-ρ receptors (formerly classified as GABAC receptors but now this nomenclature has been deprecated).

Distribution

GABAA receptors are responsible for most of the physiological activities of GABA in the central nervous system, and the receptor subtypes vary significantly. Subunit composition can vary widely between regions and subtypes may be associated with specific functions. The minimal requirement to produce a GABA-gated ion channel is the inclusion of an α and a β subunit. The most common GABAA receptor is a pentamer comprising two α's, two β's, and a γ (α1β2γ2). In neurons themselves, the type of GABAA receptor subunits and their densities can vary between cell bodies and dendrites. GABAA receptors can also be found in other tissues, including leydig cells, placenta, immune cells, liver, bone growth plates and several other endocrine tissues. Subunit expression varies between 'normal' tissue and malignancies, as GABAA receptors can influence cell proliferation.

Distribution of Receptor Types
Isoform Synaptic/Extrasynaptic Anatomical location
α1β3γ2S Both Widespread
α2β3γ2S Both Widespread
α3β3γ2S Both Reticular thalamic nucleus
α4β3γ2S Both Thalamic relay cells
α5β3γ2S Both Hippocampal pyramidal cells
α6β3γ2S Both Cerebellar granule cells
α1β2γ2S Both Widespread, most abundant
α4β3δ Extrasynaptic Thalamic relay cells
α6β3δ Extrasynaptic Cerebellar granule cells
α1β2 Extrasynaptic Widespread
α1β3 Extrasynaptic Thalamus, hypothalamus
α1β2δ Extrasynaptic Hippocampus
α4β2δ Extrasynaptic Hippocampus
α3β3θ Extrasynaptic Hypothalamus
α3β3ε Extrasynaptic Hypothalamus

Ligands

GABAA receptor and where various ligands bind.

A number of ligands have been found to bind to various sites on the GABAA receptor complex and modulate it besides GABA itself. A ligand can possess one or more properties of the following types. Unfortunately the literature often does not distinguish these types properly.

Types

  • Orthosteric agonists and antagonists: bind to the main receptor site (the site where GABA normally binds, also referred to as the "active" or "orthosteric" site). Agonists activate the receptor, resulting in increased Cl conductance. Antagonists, though they have no effect on their own, compete with GABA for binding and thereby inhibit its action, resulting in decreased Cl conductance.
  • Allosteric agonists: bind to allosteric sites on the receptor and activate the receptor in absence of orthosteric ligands.
  • First order allosteric modulators: bind to allosteric sites on the receptor complex and affect it either in a positive (PAM), negative (NAM) or neutral/silent (SAM) manner, causing increased or decreased efficiency of the main site and therefore an indirect increase or decrease in Cl conductance. SAMs do not affect the conductance, but occupy the binding site.
  • Second order modulators: bind to an allosteric site on the receptor complex and modulate the effect of first order modulators.
  • Open channel blockers: prolong ligand-receptor occupancy, activation kinetics and Cl ion flux in a subunit configuration-dependent and sensitization-state dependent manner.
  • Non-competitive channel blockers: bind to or near the central pore of the receptor complex and directly block Cl conductance through the ion channel.

Examples

Effects

Ligands which contribute to receptor activation typically have anxiolytic, anticonvulsant, amnesic, sedative, hypnotic, euphoriant, and muscle relaxant properties. Some such as muscimol and the z-drugs may also be hallucinogenic. Ligands which decrease receptor activation usually have opposite effects, including anxiogenesis and convulsion.[citation needed] Some of the subtype-selective negative allosteric modulators such as α5IA are being investigated for their nootropic effects, as well as treatments for the unwanted side effects of other GABAergic drugs.

Novel drugs

A useful property of the many benzodiazepine site allosteric modulators is that they may display selective binding to particular subsets of receptors comprising specific subunits. This allows one to determine which GABAA receptor subunit combinations are prevalent in particular brain areas and provides a clue as to which subunit combinations may be responsible for behavioral effects of drugs acting at GABAA receptors. These selective ligands may have pharmacological advantages in that they may allow dissociation of desired therapeutic effects from undesirable side effects. Few subtype selective ligands have gone into clinical use as yet, with the exception of zolpidem which is reasonably selective for α1, but several more selective compounds are in development such as the α3-selective drug adipiplon. There are many examples of subtype-selective compounds which are widely used in scientific research, including:
  • CL-218,872 (highly α1-selective agonist)
  • bretazenil (subtype-selective partial agonist)
  • imidazenil and L-838,417 (both partial agonists at some subtypes, but weak antagonists at others)
  • QH-ii-066 (full agonist highly selective for α5 subtype)
  • α5IA (selective inverse agonist for α5 subtype)
  • SL-651,498 (full agonist at α2 and α3 subtypes, and as a partial agonist at α1 and α5
  • 3-acyl-4-quinolones: selective for α1 over α3

Primate basal ganglia

From Wikipedia, the free encyclopedia

Diagram of the main components of the basal ganglia and their interconnections

The basal ganglia form a major brain system in all species of vertebrates, but in primates (including humans) there are special features that justify a separate consideration. As in other vertebrates, the primate basal ganglia can be divided into striatal, pallidal, nigral, and subthalamic components. In primates, however, there are two pallidal subdivisions called the external globus pallidus (GPe) and internal globus pallidus (GPi). Also in primates, the dorsal striatum is divided by a large tract called the internal capsule into two masses named the caudate nucleus and the putamen—in most other species no such division exists, and only the striatum as a whole is recognized. Beyond this, there is a complex circuitry of connections between the striatum and cortex that is specific to primates. This complexity reflects the difference in functioning of different cortical areas in the primate brain.

Functional imaging studies have been performed mainly using human subjects. Also, several major degenerative diseases of the basal ganglia, including Parkinson's disease and Huntington's disease, are specific to humans, although "models" of them have been proposed for other species.

Corticostriatal connection

A major output from the cortex, with axons from most of the cortical regions connecting to the striatum, is called the corticostriatal connection, part of the cortico-basal ganglia-thalamo-cortical loop. In the primate most of these axons are thin and unbranched. The striatum does not receive axons from the primary olfactory, visual or auditory cortices. The corticostriatal connection is an excitatory glutamatergic pathway. One small cortical site can project many axon branches to several parts of the striatum.

Striatum

The striatum is the largest structure of the basal ganglia.

Structure

Neuronal constitution

Medium spiny neurons (MSN)s, account for up to 95 per cent of the striatal neurons. There are two populations of these projection neurons, MSN1 and MSN2, both of which are inhibitory GABAergic. There are also various groups of GABAergic interneurons and a single group of cholinergic interneurons. These few types are responsible for the reception, processing, and relaying of all the cortical input.

Most of the dendritic spines on the medium spiny neurons synapse with cortical afferents and their axons project numerous collaterals to other neurons. The cholinergic interneurons of the primate, are very different from those of non-primates. These are said to be tonically active.

The dorsal striatum and the ventral striatum have different populations of the cholinergic interneurons showing a marked difference in shape.

Physiology

Unless stimulated by cortical input the striatal neurons are usually inactive.

Levels of organisation

The striatum is one mass of grey matter that has two different parts, a ventral and a dorsal part. The dorsal striatum contains the caudate nucleus and the putamen, and the ventral striatum contains the nucleus accumbens and the olfactory tubercle. The internal capsule is seen as dividing the two parts of the dorsal striatum. Sensorimotor input is mostly to the putamen. An associative input goes to the caudate nucleus and possibly to the nucleus accumbens.

There are two different components of the striatum differentiated by stainingstriosomes and a matrix. Striosomes are located in the matrix of the striatum and these contain μ-opioid receptors and dopamine receptor D1 binding sites.

The striatopallidal fibers give a connection from the putamen to the globus pallidus and substantia nigra.

Connectomics

Unlike the inhibitory GABAergic neurons in the neocortex that only send local connections, in the striatum these neurons send long axons to targets in the pallidum and substantia nigra. A study in macaques showed that the medium spiny neurons have several targets. Most striatal axons first target the GPe, some of these also target the GPi and both parts of the substantia nigra. There are no single axon projections to either the GPi, or to the SN, or to both of these areas; only connecting as continuing targets via axon collaterals from the striatum to the GPe.

The only difference between the axonal connectomes of the striosomes and the axons of those neurons in the matrix, is in the numbers of their branching axons. Striosomal axons cross the extent of the SN, and in macaques emit 4 to 6 vertical collaterals that form vertical columns which enter deep into the SN pars compacta (SNpc); the axons from those in the matrix are more sparsely branched. This pattern of connectivity is problematic. The main mediator of the striatopallidonigral system is GABA and there are also cotransmitters. The GPe stains for met-enkephalin, the GPi stains for either substance P or dynorphin or both, and the SN stains for both. This probably means that a single axon is able to concentrate different co-mediators in different subtrees, depending on the target.

Selectivity of striatal territories for targets

A study of the percentage of striatal axons from the sensorimotor (putamen) and associative striatum (caudate nucleus) to the globus pallidus found important differences. The GPe for instance receives a large input of axons from the associative areas. The GPi is strongly sensorimotor connected. The SN is at first associative. This is confirmed by the effects of striatal stimulations.

All the projections from the primary somatosensory cortex to the putamen, avoid the striosomes and innervate areas within the matrix.

Pallidonigral set and pacemaker

Constitution

The pallidonigral set comprises the direct targets of the striatal axons: the two nuclei of the pallidum, and the pars compacta (SNpc) and pars reticulata (SNpr) of the substantia nigra. One character of this ensemble is given by the very dense striato-pallidonigral bundle giving it its whitish aspect (pallidus means pale). In no ways has the pallidum the shape of a globe. After Foix and Nicolesco (1925) and some others, Cécile and Oskar Vogt (1941) suggested the term pallidum - also used by the Terminologia Anatomica (1998). They also proposed the term nigrum for replacing nigra, which is indeed not a substance; but this is generally not followed. The whole pallidonigral set is made up the same neuronal components. The majority is made up of very large neurons, poorly branched, strongly stained for parvalbumin, having very large dendritic arborisations (much larger in primates than in rodents) with straight and thick dendrites. Only the shape and direction of the dendritic arborizations differ between the pallidum and the SN neurons. The pallidal dendritic arborisations are very large flat and disc-shaped. Their principal plane is parallel to the others and also parallel to the lateral border of the pallidum; thus perpendicular to the axis of the afferences. Since the pallidal discs are thin, they are crossed only for a short distance by striatal axons. However, since they are wide, they are crossed by many striatal axons from wide striatal parts. Since they are loose, the chances of contact are not very high. Striatal arborisations, emit perpendicular branches participating in flat bands parallel to the lateral border, which increases the density of synapses in this direction. This is true for not only for the striatal afferent but also for the subthalamic (see below). The synaptology of the set is uncommon and characteristic. The dendrites of the pallidal or nigral axons are entirely covered by synapses, without any apposition of glia. More than 90% of synapses are of striatal origin. One noticeable property of this ensemble is that not one of its elements receives cortical afferents. Initial collaterals are present. However, in addition to the presence of various appendages at the distal extremity of the pallidal neurons that could act as elements of local circuitry, there are weak or no functional interrelations between pallidal neurons.

External globus pallidus

The external globus pallidus (GPe) or lateral globus pallidus, is flat, curved and extended in depth and width. The branching dendritic trees are disc-shaped, flat, run parallel to each other and to the pallidum border, and are perpendicular to those axons coming from the striatum. The GPe also receives input from the subthalamic nucleus, and dopaminergic input from the SNpc. The GPe does not give output to the thalamus only intrasystemically connecting to the other basal ganglia structures. It can be seen as a GABA inhibitory mediator regulating the basal ganglia. Its firing activity is very fast and exhibits long intervals of up to several seconds of silence.

In monkeys an initial inhibition was seen in response to striatal input, followed by a regulated excitation. In the study this suggested that the excitation was used temporarily to control the magnitude of the incoming signal and to spatially focus this into a limited number of pallidal neurons. GPe neurons are often multi-targeted and may respond to a number of neuron types. In macaques, axons from the GPe to the striatum account for about 15%; those to the GPi, SNpr and subthalamic nucleus are about 84%. The subthalamic nucleus was seen to be the preferred target which also sends most of its axons to the GPe.

Internal globus pallidus

The internal globus pallidus (GPi) or medial globus pallidus is only found in the primate brain and so is a younger portion of the globus pallidus. Like the GPe and the substantia nigra the GPi is a fast-spiking pacemaker but its activity does not show the long intervals of silence seen in the others. In addition to the striatal input there is also dopaminergic input from the SNpc. Unlike the GPe the GPi does have a thalamic output and a smaller output towards the habenula. It also gives output to other areas including the pedunculopontine nucleus and to the area behind the red nucleus. The evolutionary increase of the internal pallidus also brought an associated increase in the pallidothalamic tracts, and the appearance of the ventral lateral nucleus in the thalamus. The mediator is GABA.

Substantia nigra

The substantia nigra is made up of two parts, the pars compacta (SNpc) and the pars reticulata (SNpr), sometimes there is a reference to the pars lateralis but that is usually included as part of the pars reticulata. The ‘’black substance’’ that the term translates as, refers to the neuromelanin found in the dopaminergic neurons. These are found in a darker region of the SNpc. The SNpr is a lighter coloured region. There are similar cells in the substantia nigra and the globus pallidus. Both parts receive input from the striatopallidal fibres.

Pars compacta

The pars compacta is the most lateral part of the substantia nigra and sends axons to the superior colliculus. The neurons have high firing rates which make them a fast-spiking pacemaker and they are involved in ocular saccades.

Pars reticulata

The border between the SNpc and SNpr is highly convoluted with deep fringes. Its neuronal genus is the same as that of the pallidum, with the same thick and long dendritic trees. It receives its synapses from the striatum in the same way as the pallidum. Striatonigral axons from the striosomes may form columns vertically oriented entering deeply in the SNpr. The ventral dendrites of the SNpc from the reverse direction go also deeply in it. The SN also send axons to the pedunculopontine nucleus and to the parafascicular part of the central complex. The SNpr is another "fast-spiking pacemaker". Stimulations provoke no movements. Confirming anatomical data, few neurons respond to passive and active movements (there is no sensorimotor map) "but a large proportion shows responses that may be related to memory, attention or movement preparation" that would correspond to a more elaborate level than that of the medial pallidum. In addition to the massive striatopallidal connection, the SNpr receives a dopamine innervation from the SNpc and glutamatergic axons from the pars parafascicularis of the central complex. It sends nigro-thalamic axons. There is no conspicuous nigro-thalamic bundle. Axons arrive medially to the pallidal afferences at the anterior and most medial part of the lateral region of the thalamus: the ventral anterior nucleus (VA) differentiated from the ventral lateral nucleus (VL) receiving pallidal afferences. The mediator is GABA.

Striatopallidonigral connection

The striatopallidonigral connection is a very particular one. It engages the totality of spiny striatal axons. Estimated numbers are 110 million in man, 40 in chimpanzees and 12 in macaques. The striato-pallido-nigral bundle is made up of thin, poorly myelinated axons from the striatal spiny neurons grouped into pencils "converging like the spokes of a wheel" (Papez, 1941). It gives its "pale" aspect to the receiving areas. The bundle strongly stains for iron using Perls' Prussian blue (in addition to iron it contains many heavy metals including cobalt, copper, magnesium and lead).

Convergence and focusing

After the huge reduction in number of neurons between the cortex and the striatum (see corticostriate connection), the striatopallido-nigral connection is a further reduction in the number of transmitting compared to receiving neurons. Numbers indicate that, for 31 million striatal spiny neurons in macaques, there are only 166000 lateral pallidal neurons, 63000 medial pallidal, 18000 lateral nigral and 35000 in the pars reticulata. If the number of striatal neurons is divided by their total number, as an average, each target neuron may receive information from 117 striatal neurons. (Numbers in man lead to about the same ratio). A different approach starts from the mean surface of the pallidonigral target neurons and the number of synapses that they may receive. Each pallidonigral neuron may receive 70000 synapses. Each striatal neuron may contribute 680 synapses. This leads again to an approximation of 100 striatal neurons for one target neuron. This represents a huge, infrequent, reduction in neuronal connections. The consecutive compression of maps cannot preserve finely distributed maps (as in the case for instance of sensory systems). The fact that a strong anatomical possibility of convergence exists does not means that this is constantly used. A recent modeling study starting from entirely 3-d reconstructed pallidal neurons showed that their morphology alone is able to create a center-surround pattern of activity. Physiological analyses have shown a central inhibition/peripheral excitation pattern, able of focusing the pallidal response in normal conditions. Percheron and Filion (1991) thus argued for a "dynamically focused convergence". Disease, is able to alter the normal focusing. In monkeys intoxicated by MPTP, striatal stimulations lead to a large convergence on pallidal neurons and a less precise mapping. Focusing is not a property of the striatopallidal system. But, the very particular and contrasted geometry of the connection between striatal axons and pallidonigral dendrites offers particular conditions (the possibility for a very large number of combinations through local additions of simultaneous inputs to one tree or to several distant foci for instance). The disfocusing of the system is thought to be responsible for most of the parkinsonian series symptoms. The mechanism of focusing is not known yet. The structure of the dopaminergic innervation does not seem to allow it to operate for this function. More likely focusing is regulated by the upstream striatopallidal and corticostriatal systems.

Synaptology and combinatory

The synaptology of the striato- pallidonigral connection is so peculiar as to be recognized easily. Pallidonigral dendrites are entirely covered with synapses without any apposition of glia. This gives in sections characteristic images of "pallissades" or of "rosettes". More than 90% of these synapses are of striatal origin. The few other synapses such as the dopaminergic or the cholinergic are interspersed among the GABAergic striatonigral synapses. The way striatal axons distribute their synapses is a disputed point. The fact that striatal axons are seen parallel to dendrites as "woolly fibers" has led to exaggerate the distances along which dendrites and axons are parallel. Striatal axons may in fact simply cross the dendrite and give a single synapse. More frequently the striatal axon curves its course and follow the dendrite forming "parallel contacts" for a rather short distance. The average length of parallel contacts was found to be 55 micrometres with 3 to 10 boutons (synapses). In another type of axonal pattern the afferent axon bifurcates and gives two or more branches, parallel to the dendrite, thus increasing the number of synapses given by one striatal axon. The same axon may reach other parts of the same dendritic arborisation (forming "random cascades") With this pattern, it is more than likely that 1 or even 5 striatal axons are not able to influence (to inhibit) the activity of one pallidal neuron. Certain spatio-temporal conditions would be necessary for this, implying more afferent axons.

Pallidonigral outmaps

What is described above concerned the input map or "inmap" (corresponding to the spatial distribution of the afferent axons from one source to one target). This does not correspond necessarily to the output map or outmap (corresponding to the distribution of the neurons in relation to their axonal targets). Physiological studies and transsynaptic viral markers have shown that islands of pallidal neurons (only their cell bodies or somata, or trigger points) sending their axons through their particular thalamic territories (or nuclei) to one determined cortical target are organized into radial bands. These were assested to be totally representative of the pallidal organisation. This is certainly not the case. Pallidum is precisely one cerebral place where there is a dramatic change between one afferent geometry and a completely different efferent one. The inmap and the outmap are totally different. This is an indication of the fundamental role of the pallidonigral set: the spatial reorganisation of information for a particular "function", which is predictably a particular reorganisation within the thalamus preparing a distribution to the cortex. The outmap of the nigra (lateralis reticulata) is less differentiated.

Substantia nigra compacta (SNpc) and nearby dopaminergic elements

In strict sense, the pars compacta is a part of the core of basal ganglia core since it directly receives synapses from striatal axons through the striatopallidonigral bundle. The long ventral dendrites of the pars compacta indeed plunge deep in the pars reticulata where they receive synapses from the bundle. However, its constitution, physiology and mediator contrast with the rest of the nigra. This explains why it is analysed here between the elements of the core and the regulators. Ageing leads to the blackening of its cell bodies, by deposit of melanin, visible by naked eye. This is the origin of the name of the ensemble, first "locus niger" (Vicq d'Azyr), meaning black place, and then "substantia nigra" (Sömmerring), meaning black substance.

Structure

The densely distributed neurons of the pars compacta have larger and thicker dendritic arborizations than those of the pars reticulata and lateralis. The ventral dendrites descending in the pars reticulata receives inhibitory synapses from the initial axonal collaterals of pars reticulata neurons (Hajos and Greefield, 1994). Groups of dopaminergic neurons located more dorsally and posteriorly in the tegmentum are of the same type without forming true nuclei. The "cell groups A8 and A10" are spread inside the cerebral peduncule. They are not known to receive striatal afferences and are not in a topographical position to do so. The dopaminergic ensemble is thus also on this point inhomogeneous. This is another major difference with the pallidonigral ensemble. The axons of the dopaminergic neurons, that are thin and varicose, leave the nigra dorsally. They turn round the medial border of the subthalamic nucleus, enter the H2 field above the subthalamic nucleus, then cross the internal capsule to reach the upper part of the medial pallidum where they enter the pallidal laminae, from which they enter the striatum. They end intensively but inhomogeneously in the striatum, rather in the matrix of the anterior part and rather in the striosomes dorsalwards. These authors insit on the extrastriatal dopaminergic innervation of other elements of the basal ganglia system: pallidum and subthalamic nucleus.

Physiology

Contrarily to the neurons of the pars reticulata-lateralis, dopaminergic neurons are "low-spiking pacemakers", spiking at low frequency (0,2 to 10 Hz) (below 8, Schultz). The role of the dopaminergic neurons has been the source of a considerable literature. As the pathological disappearance of the black neurons was linked to the appearance of Parkinson's disease, their activity was thought to be "motor" . A major discovery has been that the stimulation of the black neurons had no motor effect. Their activity is in fact linked to reward and prediction of reward. In a recent review (Schultz 2007), it is demonstrated that phasic responses to reward-related events, notably reward-prediction errors, ...lead to ..dopamine release..." While it is thought that there could be different behavioral processes including long time regulation. Due to its widespread distribution, the dopaminergic system may regulate the basal ganglia system in many places.

Regulators of the basal ganglia core

Subthalamic nucleus, or corpus Luysi

As indicated by its name, the subthalamic nucleus is located below the thalamus; dorsally to the substantia nigra and medial to the internal capsule. The subthalamic nucleus is lenticular in form and of homogeneous aspect. It is made up of a particular neuronal species having rather long ellipsoid dendritic arborisations, devoid of spines, mimicking the shape of the whole nucleus. The subthalamic neurons are "fast-spiking pacemakers" spiking at 80 to 90 Hz. There are also about 7,5% of GABA microneurons participating in the local circuitry. The subthalamic nucleus receives its main afference from the lateral pallidum. Another afference comes from the cerebral cortex (glutamatergic), particularly from the motor cortex, which is too much neglected in models. A cortical excitation, via the subthalamic nucleus provokes an early short latency excitation leading to an inhibition in pallidal neurons. Subthalamic axons leave the nucleus dorsally. Except for the connection to the striatum (17.3% in macaques), most of the principal neurons are multitargets and ffed axons to the other elements of the core of the basal ganglia. Some send axons to the substantia nigra medially and the medial and lateral nuclei of the pallidum laterally (3-target 21.3%). Some are 2-target with the lateral pallidum and the substantia nigra (2.7%) or the lateral pallidum and the medial(48%). Fewer are single target for the lateral pallidum. If one adds all those reaching this target, the main afference of the subthalamic nucleus is, in 82.7% of the cases, the lateral pallidum (external segment of the globus pallidus. While striatopallidal and the pallido-subthalamic connections are inhibitory (GABA), the subthalamic nucleus utilises the excitatory neurotransmitter glutamate. Its lesion resulting in hemiballismus is known for long. Deep brain stimulation of the nucleus suppress most of the symptoms of the Parkinson' syndrome, particularly dyskinesia induced by dopamine therapy.

Subthalamo-lateropallidal pacemaker

As said before, the lateral pallidum has purely intrinsic basal ganglia targets. It is particularly linked to the subthalamic nucleus by two-way connections. Contrary to the two output sources (medial pallidum and nigra reticulata), neither the lateral pallidum nor the subthalmic nucleus send axons to the thalamus. The subthalamic nucleus and lateral pallidum are both fast-firing pacemakers. Together they constitute the "central pacemaker of the basal ganglia" with synchronous bursts. The pallido-subthalamic connection is inhibitory, the subthalamo-pallidal is excitatory. They are coupled regulators or coupled autonomous oscillators, the analysis of which has been insufficiently deepened. The lateral pallidum receives a lot of striatal axons, the subthalamic nucleus not. The subthalamic nucleus receives cortical axons, the pallidum not. The subsystem they make with their inputs and outputs corresponds to a classical systemic feedback circuit but it is evidently more complex.

Central region of the thalamus

The centromedian nucleus is in the central region of the thalamus. In upper primates it has three parts instead of two, with their own types of neuron. Output from here goes to the subthalamic nucleus and the putamen. Its input includes fibers from the cortex and globus pallidus.

Pedunculopontine complex

The pedunculopontine nucleus is a part of the reticular formation in the brainstem and a main component of the reticular activating system, and gives a major input to the basal ganglia. As indicated by its name, it is located at the junction between the pons and the cerebral peduncle, and near the substantia nigra. The axons are either excitatory or inhibitory and mainly target the substantia nigra. Another strong input is to the subthalamic nucleus. Other targets are the GPi and the striatum. The complex receives direct afferences from the cortex and above all abundant direct afferences from the medial pallidum (inhibitory). It sends axons to the pallidal territory of the VL. The activity of the neurons is modified by movement, and precede it. All this led Mena-Segovia et al. (2004) to propose that the complex be linked in a way or another to the basal ganglia system. A review on its role in the system and in diseases is given by Pahapill and Lozano (2000). It plays an important role in awakeness and sleep. It has a dual role as a regulator of, and of being regulated by the basal ganglia.

Outputs of the basal ganglia system

In the cortico-basal ganglia-thalamo-cortical loop the basal ganglia are interconnected, with little output to external targets. One target is the superior colliculus, from the pars reticulata. The two other major output subsystems are to the thalamus and from there to the cortex. In the thalamus the GPimedial fibers are separated from the nigral as their terminal arborisations do not mix. The thalamus relays the nigral output to the premotor and to the frontal cortices.

Medial pallidum to thalamic VL and from there to cortex

The thalamic fasciculus (H1 field) consists of fibers from the ansa lenticularis and from the lenticular fasciculus (H2 field), coming from different portions of the GPi. These tracts are collectively the pallidothalamic tracts and join before they enter the ventral anterior nucleus of the thalamus.

Pallidal axons have their own territory in the ventral lateral nucleus (VL); separated from the cerebellar and nigral territories. The VL is stained for calbindin and acetylcholinesterase. The axons ascend in the nucleus where they branch profusely. The VL output goes preferentially to the supplementary motor cortex (SMA), to the preSMA and to a lesser extent to the motor cortex. The pallidothalamic axons give branches to the pars media of the central complex which sends axons to the premotor and accessory motor cortex.

SNpr to thalamic VA and from there to cortex

The ventral anterior nucleus (VA) output targets the premotor cortex, the anterior cingulate cortex and the oculomotor cortex, without significant connection to the motor cortex.

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