Neuroscience 222 (2012) 8999
EPILEPSY: EVER-CHANGING STATES OF CORTICAL EXCITABILITY
R. A. B. BADAWY, a,b,c* D. R. FREESTONE, c A. LAI d AND
M. J. COOK a,b
a
Department of Clinical Neurosciences, St Vincents Hospital,
Fitzroy, Australia
b
Department of Medicine, The University of Melbourne,
Parkville, Australia
c
Department of Electrical and Electronic Engineering, The University
of Melbourne, Parkville, Australia
d
Bionics Institute, East Melbourne, Victoria, Australia
AbstractIt has been proposed that the underlying epileptic
process is mediated by changes in both excitatory and inhib-
itory circuits leading to the formation of hyper-
excitable seizure networks. In this review we aim to shed light
on the many physiological factors that modulate excitability
within these networks. These factors have been discussed
extensively in many reviews each as a separate entity and
cannot be extensively covered in a single manuscript. Thus
for the purpose of this work in which we aim to bring those
factors together to explain how they interact with epilepsy,
we only provide brief descriptions. We present reported evi-
dence supporting the existence of the epileptic brain in sev-
eral states; interictal, peri-ictal and ictal, each with distinct
excitability features. We then provide an overview of how
many physiological factors inuence the excitatory/inhibi-
tory balance within the interictal state, where the networks
are presumed to be functioning normally. We conclude that
these changes result in constantly changing states of cortical
excitability in patients with epilepsy. 2012 IBRO. Published
by Elsevier Ltd. All rights reserved.
Key words: epilepsy, cortical excitability, seizures, peri-ictal,
physiological variations, stress.
INTRODUCTION
Epilepsy is a disorder characterized by the occurrence of
recurrent seizures. These seizures reect abnormal
*Correspondence to: R. A. B. Badawy, Department of Clinical
Neurosciences, St Vincents Hospital, 41 Victoria Parade Fitzroy,
Victoria 3065, Australia. Tel: +61-3-9288-3068; fax: +61-3-9288-
3350.
E-mail addresses: badawyr@unimelb.edu.au, rdwbadawy@yahoo.
com (R. A. B. Badawy).
Abbreviations: ACTH, adrenocorticotropic hormone; BECTS, benign
childhood epilepsy with centro-temporal spikes; BFNIS, benign familial
neonatal-infantile seizures; CRF, corticotropin-releasing factor; EEG,
electroencephalogram; fMRI, functional magnetic resonance imaging;
GABA, gamma (c)-aminobutyric acid; GTCs, generalized tonicclonic
seizures; IGE, idiopathic generalized epilepsy; LGS, LennoxGastaut
syndrome; NREM, non rapid eye movement; REM, rapid eye move-
ment; SCN, suprachiasmatic nuclei; SMEI, severe myoclonic epilepsy
of infancy.
0306-4522/12 $36.00 2012 IBRO. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.neuroscience.2012.07.015
89
hypersynchronous electrical activity of neuronal networks,
which are thought to be caused by an imbalance between
excitation and inhibition (McCormick and Contreras,
2001). The ratio of excitation to inhibition is the major deter-
minant of excitability in the brain. Epileptogenesis refers to
the alteration of a normal neuronal network into a hyper-
excitable network leading recurrent, spontaneous seizures
to occur (Clark and Wilson, 1999). The proposed underly-
ing mechanisms for this process include neuronal loss,
neurogenesis, glial loss, gliogenesis, axonal and dendritic
plasticity and intracellular channelopathies or receptor dys-
function. A complete discussion of these mechanisms is
beyond the scope of this review and is extensively
described elsewhere. The aim of this review is to draw
attention to the dynamic variability in cortical excitability
within each individual with epilepsy. The epileptic brain
exists in many states, not just the well-established appar-
ently normal or interictal state in between seizures during
which the brain appears to function normally, and abnormal
orictal state characterized by widespread synchronous
activity occurring in a paroxysmal way, thereby impairing
brain functioning (Lopes da Silva et al., 2003). Not only
are these two states separated by the preictal state during
which physiological phenomena such as prodromal symp-
toms can occur and the postictal state during which the
brain is recovering from the seizure, there are also many
variations in cortical excitability within the interictal state it-
self. These changes are inuenced by many physiological
factors each of which has been the subject of multiple
extensive reviews describing their pathophysiological ba-
sis and their relationship with epilepsy. To attempt to pro-
vide an exhaustive or full review of each in a single
manuscript would be an unrealistic and unachievable goal
and is far from our intention. We present a brief overview
of these factors to show how they can all co-exist in the same
person and inuence clinical presentation. We attempt to
draw the bigger picture; to demonstrate the complex interac-
tion that results in constantly changing states of cortical
excitability in patients with epilepsy.
VARIATIONS IN INTERICTAL CORTICAL
EXCITABILITY
Sleepwake cycle
The relationship between sleep and epilepsy is well rec-
ognized. Most studies conrm that sleep and circadian
variations in arousal not only aect the timing of seizure
occurrence, but also the frequency, morphology and
spread of interictal discharges on electroencephalogram
(EEG). Synchronized non rapid eye movement (NREM)
sleep facilitates seizures, whereas desynchronized rapid
90 R. A. B. Badawy et al. / Neuroscience 222 (2012) 8999

eye movement (REM) sleep discourages seizure occur-
rence (Foldvary-Schaefer and Grigg-Damberger, 2009).
The majority of generalized tonicclonic seizures
(GTCs) in all forms of idiopathic generalized epilepsy
(IGE) occur after awakening and is particularly likely to
happen when the person is aroused after sleep deprivation
followed by brief sleep. This relationship to epilepsy on
awakening is particularly clear in patients with juvenile
myoclonic epilepsy (Niedermeyer et al., 1985). Patients
with IGE also show variation in the occurrence of interictal
epileptiform discharges with sleep. Interictal epileptiform
discharges are usually present in the wake EEG, but sleep
further activates interictal epileptiform discharges in
patients with absence and/or GTCs (Sato et al., 1973).
Typically, spikes increase with sleep onset progressively
through NREM 3, diminish sharply in REM sleep, and in-
crease again in the morning after awakening. During
NREM sleep, generalized spike-wave discharges often
become more disorganized, increase in amplitude and
slow in frequency, sometimes with the addition of poly-
spikes, whereas the morphology in REM sleep is similar
to wakefulness (Fig. 1).
In focal epilepsy, timing of seizures appears to be gov-
erned by the type and location of the epileptic focus as well.
Seizures of mesial temporal origin may be particularly vul-
nerable to these eects. Seizures in patients with mesial
temporal lobe epilepsy (MTLE) tend to occur more
frequently during the day than during the night (Quigg
et al., 1998), while seizures in patients with extra-temporal
epilepsy seizures are more likely to occur during sleep
(Crespel et al., 1998). This is particularly more common
in patients with frontal lobe epilepsies in whom seizures
tend to cluster during sleep, almost exclusively during
NREM sleep. In addition, secondary generalization of
partial seizures tends to occur more often during sleep
compared with wakefulness, being more common in
temporal lobe than frontal lobe seizures (Fig. 1).
Focal interictal discharges are much more common
during sleep than during wakefulness (Sammaritano
et al., 1991). Interictal spikes increase at sleep onset,
peaking in NREM 3, and then falling in REM sleep to lev-
els lower than wakefulness. In addition, the eld of an
interictal discharge typically enlarges during NREM sleep,
occasionally accompanied by new foci, and becomes

Fig. 1. Schematic showing distribution of seizures and epileptiform discharges across a typical 24-h sleep cycle for generalized and focal
epilepsies. The sleep stages are scored based on normal sleep cycling between non-rapid eye movement sleep stages 14 (NREM14) and rapid
eye movement sleep; (REM) cycle during the night. IEDs, interictal discharges; IGE, idiopathic generalized epilepsy; JME, juvenile myoclonic
epilepsy; FLE, frontal lobe epilepsy; TLE, temporal lobe epilepsy.
 R. A. B. Badawy et al. / Neuroscience 222 (2012) 8999
more diuse in NREM 3 compared with NREM 1 and 2
and more constricted during REM sleep.
The circadian oscillations within the neuronal net-
works that generate wakefulness, NREM, and REM sleep
are driven by the suprachiasmatic nuclei (SCN), the dom-
inant circadian pacemaker in the mammalian brain. It is
still unknown how this molecular clockwork is controlled
by extracellular neuro-hormones and neurotransmitters
and which membrane receptors undergo circadian modu-
lation. The principal neurotransmitter on SCN synapses is
gamma (c)-aminobutyric acid (GABA), which acts at post-
synaptic GABAA receptors. Studies have shown that there
is daily variation in the postsynaptic GABAA-mediated
functions in the SCN (Kretschmannova et al., 2005).
Observations from patch-clamp studies suggest that
levels of synaptically released GABA from the terminals
of SCN output neurons can inuence the relative contribu-
tion of pre- versus postsynaptic GABAB receptors in mod-
ulating both excitatory and inhibitory SCN innervation to
parvo-cellular neurons in the thalamus (Wang et al.,
2003). These studies also report diurnal uctuations in
spontaneous excitatory postsynaptic activity within this
network that may contribute to the mechanisms for syn-
chronization of rhythms between individual SCN neurons
and may underlie the circadian variations in the spontane-
ous ring frequency of SCN neurons (Lundkvist et al.,
2002).
Sleep is induced by GABA-ergic cells located in the
basal forebrain and in the anterior hypothalamus. Cholin-
ergic neurons in the basal forebrain are directly inhibited
by GABA-ergic sleep active neurons leading to deactiva-
tion of the cortex. These cells are more active during
NREM sleep than they are during REM sleep or during
wakefulness and they also increase discharge rates with
sleep onset and continue to release GABA with increasing
levels as sleep continues (Siegel, 2004).
In generalized epilepsies, reduced cellular discharges
and chemical release in reticulo-thalamic pathways pro-
mote interictal epileptiform discharge generation during
NREM sleep, probably by enhancing the thalamo-cortical
EEG synchronization patterns that are associated with
spike-wave complexes. Sleep transients such as sleep
spindles and possibly even delta waves are contingent on
hyperpolarising GABA-ergic input from the thalamic reticu-
lar nucleus to the thalamo-cortical relay cells. Increased
GABA release from thalamic and cortical neurons is con-
sidered critical to the generation of the slow component
of these discharges (McCormick and Contreras, 2001).
Although the peak in GABA release that occurs during
NREM promotes interictal epileptiform discharges, it
seems to discourage clinically evident seizures such as
myoclonic jerks or GTCs. On the other hand, the moderate
level of reticular activation, chemical release and synchro-
nous thalamo-cortical discharge patterns during drowsi-
ness are conducive to generalized epileptic discharge
propagation with clinical accompaniment. In contrast to
NREM and drowsiness, extreme activation of ascending
brainstem aerents, particularly cholinergic cells that
occurs during wakefulness and REM sleep, abolishes
GABA-mediated synchronous thalamo-cortical discharge
oscillations and leads to desynchronization of the EEG.
91
This is thought to suppress both ictal and interictal events
during REM sleep and wakefulness (Shouse et al., 2000).
Much less is known about how sleep modulates epilep-
tic discharges and seizures in focal epilepsies. Reduced
electrochemical activity in reticulo-limbic pathways most
parsimoniously explains interictal propagation from tempo-
ral or frontal lobe foci during NREM sleep. The eects could
be mediated by direct innervation of focal epileptic neurons.
Studies indicate that local application of noradrenaline
receptor antagonists to limbic seizure foci promotes ictal
discharge propagation, whereas noradrenaline receptor
antagonists block seizure discharge generalization
(Shouse et al., 2000). In a recent transcranial magnetic
stimulation study involving patients with nocturnal frontal
lobe epilepsies, a marked decrease in intracortical inhibi-
tion during NREM sleep was found (Salih et al., 2007).
Mutations in genes coding for subunits of the neuronal nic-
otinic acetylcholine receptors (nAChRs) present in families
with autosomal dominant nocturnal frontal lobe epilepsies
result in a gain in receptor function (Marini and Guerrini,
2007). These studies suggest that increased response to
acetylcholine and enhanced GABA-ergic function may be
the basis for epileptogenesis in nocturnal frontal lobe
epilepsies.
Hormonal variations
Hormones associated with stress. Stress, and emo-
tional stress in particular, is ranked consistently as the most
common trigger of seizures independent of the type of
epilepsy (Frucht et al., 2000). Some have argued this is
predominantly due to the common association of sleep
deprivation and medication noncompliance with stress
(Frucht et al., 2000; Haut et al., 2007). However, there is
also a connection between stress and seizures indepen-
dent of these two factors (Haut et al., 2007). This is further
shown in a study demonstrating that audio and video
recordings designed to elicit empathetically stressful
responses were sucient to induce spontaneous seizures
in patients with epilepsy (Feldman and Paul, 1976).
Moreover, patients with refractory epilepsy tend to report
triggering factors, such as stress, more often than patients
whose seizures are well controlled with medication. This
nding underscores the potential therapeutic benets of
managing stress in patients with epilepsy (Sperling et al.,
2008). When faced with a stressful situation, faster, more
instinctual mechanisms regulated by the amygdala, hippo-
campus, and striatum take over, superseding the more log-
ical and analytical functions of the frontal cortex (Arnsten,
1998). The physiologic stress response is often divided into
two separate yet linked systems acting in a coordinated
temporal manner. The rapid response to a stressor
involves the sympathetic-adrenomedullary system, which
results in the activation of the sympathetic nervous system,
increased systemic levels of norepinephrine and epineph-
rine, and increased levels of norepinephrine in the brain.
The slower, longer-lasting response to a stressor involves
the hypothalamicpituitaryadrenal axis and begins
with the paraventricular nucleus of the hypothalamus
92 R. A. B. Badawy et al. / Neuroscience 222 (2012) 8999
releasing corticotropin-releasing factor (CRF) (de Kloet
et al., 2005). CRF is also present in the amygdala, hippo-
campus and cortex (Dunn and Berridge, 1990). It is an
important hormone in the regulation of the response to
stress and can act as an excitatory neurotransmitter or neu-
romodulator (Dunn and Berridge, 1990). It may also con-
tribute to seizure-related neuronal loss (Ribak and
Baram, 1996). CRF stimulates the pituitary to release adre-
nocorticotropic hormone (ACTH) into the bloodstream.
ACTH stimulates release of glucocorticoids, which
mobilize peripheral energy stores, dampen the immune re-
sponse, and act as mediators in negative feedback control
of the HPA axis (de Kloet et al., 2005). Glucocorticoids
including corticosterone and dexamethasone, facilitate
epileptiform discharges and seizures in animals. This eect
may be mediated by type II glucocorticoid receptors, which
have a diuse distribution in the brain (Paul and Purdy,
1992). The HPA axis and sympathetic-adrenomedullary
system work in conjunction with one another to coordinate
adaptive responses to a stressor. Chronic glucocorticoid
excess in the setting of chronic stress results in hippocam-
pal neuronal loss and loss of dendritic spines and branch-
ing (Sapolsky et al., 1990). This was postulated to occur
by potentiating NMDA receptor-dependent neurotoxicity.
Menstrual cycle and pregnancy. Many women with
epilepsy experience changes in seizure frequency and
severity over the menstrual cycle and with pregnancy.
The eect of pregnancy on seizure susceptibility is vari-
able, with no conclusive evidence of the eect of pregnancy
on seizure frequency (Harden et al., 2009). On the other
hand, it is well documented that seizures in many women
with epilepsy tend to cluster in relation to the menstrual
cycle, a condition referred to as catamenial epilepsy.
Usually, seizure exacerbation occurs during the peri-
menstrual phase or peri-ovulatory phase or during the
entire second half of menstrual cycles (Herzog et al.,
1997). This phenomenon has largely been attributed to
the neuroactive properties of steroid hormones and the
cyclic variations in their serum levels. Oestrogen increases
late in the follicular (pre-ovulatory) phase and then gradually
declines during the luteal (pre-menstrual) phase. It has
been shown to lower seizure thresholds in most adult animal
studies (Nicoletti et al., 1985). This eect on neuronal excit-
ability is mediated by increases in glutamate (Wong et al.,
1996) through cytosolic neuronal oestrogen receptors.
Progesterone, on the other hand, increases late in the
follicular phase and then gradually declines during the
luteal phase. It potentiates GABA-mediated inhibition
mainly by increasing the activity of GABAA receptors
(Kokate et al., 1994). This depresses neuronal ring, less-
ens epileptiform discharges and elevates seizure threshold
(Nicoletti et al., 1985).
Given these competing properties, if seizure exacerba-
tion in women with epilepsy is linked to uctuations in sex
hormone levels it would be predicted that this would typi-
cally occur when the oestrogen/progesterone ratio is at
its peak. This occurs during ovulation when oestrogen lev-
els are at their highest or right before and during menstru-
ation when the decline in progesterone can be regarded
as pro-convulsant. Indeed, these patterns are seen in
some women with catamenial epilepsy (Herzog, 2008).
However, seizure exacerbation during the entire second
half of the cycle (luteal phase) when progesterone levels
are expected to be high is also commonly reported (Herzog
et al., 2004). This may be due to an inadequate luteal phase
with insucient rise in progesterone levels to be protective
against seizures in these women (Herzog, 2008). Clinical
data indicating that the catamenial pattern of seizure exac-
erbation is more often observed in women with temporal
lobe epilepsy (Herzog et al., 2004), where reproductive
endocrine disorders such as anovulatory cycles and oligo-
menorhea are also commonly present (Morrell, 1998), and
may also support this proposition. However, this is not a
universal nding (Murri and Galli, 1997). Furthermore,
while most animal studies conclude that oestrogen has
pro-convulsant eects, there is evidence this eect is inu-
enced by the region, the neurotransmitter system, the sei-
zure type, the animal model, the distinct expression of
individual oestrogen receptor types, and the distinct
modulatory eects of oestrogens on the neurotransmitter
system involved in seizure genesis (Veliskova, 2007).
Some studies even report an anti-convulsant eect of
b-estradiol, which is one of the main metabolites of oestro-
gen (Veliskova, 2006).
It is known that progesterone metabolites function as
potent positive modulators of the GABAA receptor (Kokate
et al., 1994; Scharfman and MacLusky, 2006). However,
uctuations in the circulating levels of this steroid at pub-
erty, during pregnancy, or following chronic stress produce
periods of prolonged exposure and withdrawal. This can
cause changes in GABAA receptor subunit composition
to compensate for sustained levels of inhibition (Smith
et al., 2007). These changes have been shown to pro-
foundly alter GABAA receptor structure and function
(Maguire and Mody, 2009) and subsequent seizure exac-
erbation in catamenial epilepsy. These data indicate that
there is a highly complex interaction between hormones
and the neurotransmitter systems in patients with epilepsy.
This interaction is likely to inuence patterns of cortical
excitability and seizure risk across the menstrual cycle.
Blood sugar levels
Blood glucose levels show natural variability, and in gen-
eral, levels are lower after lack of food for extended periods
of time or following exercise. The relationship between
these uctuations and cortical excitability is largely
unknown. There are several reports of seizures triggered
with lack of food or after prolonged exercise (Frucht et al.,
2000). Seizures are also very common in patients with
impaired transport of glucose across the bloodbrain bar-
rier due to deciency of the major brain glucose transporter
GLUT1 (Roulet-Perez et al., 2008). These seizures can
occur in the classical severe GLUT1 encephalopathy, but
also in milder cases that have otherwise typical idiopathic
generalized epilepsy. Those patients respond to oral glu-
cose with signicant improvement in both clinical seizures
and EEG ndings (Suls et al., 2008). It is also well known
that seizures can occur as a complication to severe hypogly-
caemia induced by excess insulin (Malouf and Brust, 1985)
and epileptiform discharges have been recorded on EEG in
the setting of extreme hypoglycaemia. These changes are
 R. A. B. Badawy et al. / Neuroscience 222 (2012) 8999
reversed by glucose administration (Niedermeyer and
Lopes da Silva, 2005). It could be that variability in blood
glucose levels is associated with uctuations in cortical
excitability. These changes may be sucient to change
seizure threshold in certain patients.
TRANSITION FROM THE INTERICTAL TO THE
ICTAL STATE
Epilepsy is regarded as a chronic and persistent condition
with a persistent pathology. Therefore, it is fair to ask why
the symptoms are (seizures for example) not persistent.
The answer to this important question lies in the under-
standing of the ever-changing state of cortical excitability.
The intermittency of epileptic seizures poses major chal-
lenges in developing robust treatments. Therefore, under-
standing the mechanisms underlying the transformation
between the relatively normal interictal brain state and
clinical seizures (the ictal transition) is critically important.
Seizures generally occur without warning and
because of that it has largely been assumed that the shift
between the interictal and ictal states occurs as an abrupt
phenomenon. Over recent years, there is growing evi-
dence to indicate that this two-state model is inaccurate,
and that there is a prolonged transitional peri-ictal phase
between the seizure and the interictal state. Preictal pro-
dromal symptoms such as irritability or headache are fre-
quently reported by patients minutes, hours or even days
prior to clinical seizure onset (Delamont et al., 1999). Fol-
lowing a seizure, postictal changes such as confusion and
amnesia are commonly encountered by patients, making
the postictal period for some patients even more disturb-
ing than the seizure itself. In addition, postictal features
are frequently seen on EEG recordings and include regio-
nal or diuse polymorphic delta activity, attenuation of
EEG rhythms or activation of focal spikes lasting for up
to hours following seizures (Kaibara and Blume, 1988).
Animal studies, show evidence that seizure initiation
depends on a loss of inhibitory control of the epileptogenic
zone resulting in increased excitability of neighbouring
neurons facilitating the spread of seizure activity (Depaulis
et al., 1994). Theoretical studies, involving mathematical
modelling, have demonstrated that seizure initiation may
result from multiple mechanisms. An important study by
Lopes Da Silva et al. (Lopes da Silva et al., 2003) hypoth-
esized three routes to seizures. The rst transition is mod-
elled by a jump from normal brain dynamics to seizure
that is trigged by intrinsic neural noise or a particular stim-
ulus. This is illustrated in Fig. 2 where the brain state is
indicated by the grey ball. With no input, the ball will rest
at the bottom of the well (lowest energy point) on the left-
hand side. This position would correspond to the idle state
of the brain, such as alpha activity. With perturbations,
say sensory input, the brain state is free to roll along the
surface in the normal (green) region. The brain state is
eectively trapped in the healthy region and cannot tran-
sition to a seizure without an extremely large perturbation
to overcome the barrier. The brain can, however, still tran-
sition to the seizure state with a high-energy input (i.e.
electrical stimulation) or an extreme level of excitability.
Conversely in the epileptic brain, the transition threshold
93
(marked by the dashed line in Fig. 2) is lower enabling
transitions to seizure to be trigged by normal uctuations,
with a sucient level of excitability. This is the seizure
transition that Lopes Da Silva referred to as bi-stability.
Within this scenario, seizures are thought to be unpredict-
able as intrinsic neural noise (random walk) may trigger
the transition to seizure.
The second scenario presented by Lopes Da Silva
and his colleagues (Lopes da Silva et al., 2003) can be
described by a deformation of the surface that the ball
rolls along, such that the barrier gradually moves to the
right into the epileptic region with physiological changes.
Tracking the aspect of the physiology that deforms the
surface is the goal of seizure prediction.
The third scenario is changes in an exogenous param-
eter, or input, that triggers seizures without any underlying
changes within the brain. An example of this kind is the
well-known photosensitive epilepsy, where ickering light
may trigger seizures. Another example of seizures of this
kind is from the maximal electro-shock rat model of epi-
lepsy (Nelson et al., 2010). In this animal model, seizures
are initiated by electrically stimulating the motor cortex
(M1 region) of normally healthy rats.
It is likely that a combination of the theoretical transi-
tions to seizure presented by Lopes da Silva et al. (2003)
occurs in particular situations. For example, as discussed
in the previous sections there is evidence that seizures
cluster to particular times of the day, week or month. It is
well known that seizures cluster around times of stress,
sleep deprivation and around menstrual cycles (Frucht
et al., 2000). During these times of high seizure susceptibil-
ity it has been shown that, with care, patients can avoid sei-
zures (Spector et al., 2000). Therefore, it is reasonable to
consider these times of stress as a necessary but not suf-
cient condition for seizure occurrence. In this scenario, a
combination of hyper-excitability (deformed dynamical
landscape) and a particular exogenous input may be
required to trigger an epileptic event.
The pre-seizure or pro-seizure hyper-excitable state has
been measured by multiple imaging modalities, but studies
using intracranial EEG have dominated the literature. This
is due to accessibility of data and the high delity of the
recordings. These studies report changes in neuronal com-
plexity and network activity on linear (Esteller et al., 2005)
and non-linear EEG analysis (Martinerie et al., 1998; Litt
et al., 2001; Iasemidis et al., 2005, Le Van Quyen, 2005),
optical recording of intrinsic signals (Zhao et al., 2007) and
a probing-stimulation technique (Kalitzin et al., 2005;
Freestone et al., 2011). These changes last from seconds
to hours prior to seizure onset. Over the past 4 decades this
has evolved into the eld of epileptic seizure prediction and
control, with the goal to detect an impending seizure and
stop it before it manifests clinically. A limitation of intracranial
EEG studies is that they typically use features of the signals
that are abstractions of what we really want to measure. This
is illustrated in Fig. 3 that depicts a cascade of events that
culminate in seizures. The goal of experimental studies in
monitoring pre-seizure excitability should be to track physio-
logical variables as far to the left, upstream in the cascade,
as possible. A critical link in the seizure cascade is the
increase in excitability. Another way is to use functional
94 R. A. B. Badawy et al. / Neuroscience 222 (2012) 8999

Fig. 2. A simplied version of the dynamical landscape of healthy and epileptic brains. The solid black line within the axes represents a simplied
version of the brains dynamical landscape. The ball marks the current state of the brain. The ball (state) is free to roll across the landscape if it is
perturbed by an input. With a higher level of excitability the ball will have more energy to roll away from the trough given a perturbation from an input
or endogenous activity. In the epileptic brain, the landscape is deformed and the barrier between the normal and epileptic states is lower. Therefore,
given a suciently high level of excitability and a particular input the transition to seizure may occur more easily than the healthy brain.

Fig. 3. The seizure cascade. From left to right is a causally related cascade of events that may lead to epileptic seizures.

MRI (fMRI), a technique that assesses cerebral activity by
detecting signal changes related to focal alterations of de-
oxyhaemoglobin concentration (Ogawa and Lee, 1990).
This has demonstrated signicant fMRI signal changes
occurring several minutes before the onset of seizures that
could be localized to the site of the presumed seizure focus,
as well as to other brain regions (Federico et al., 2005). Non-
equivocal evidence of a marked increase in cortical excitabil-
ity changes lasting for up to 2448 h before a seizure was
also found on transcranial magnetic stimulation studies
(Wright et al., 2006; Badawy et al., 2009).
Seizure termination is thought to be modulated by
both synaptic excitation and inhibition and is character-
ized by a strong depolarizing shift (block), hyperpolariza-
tion and recovery of neurons in all cortical areas (Pinto
et al., 2005). There is also evidence of relative hypoperfu-
sion in the hippocampus associated with the cessation of
neuronal ictal discharges on postictal brain perfusion
studies (Leonhardt et al., 2005). A prolonged marked
reduction in cortical excitability was also reported on
transcranial magnetic stimulation lasting for up to 24 h
postictally (Badawy et al., 2009). This demonstrated cor-
tical inhibition, possibly creates a physiological postictal
state that is likely to reduce the risk of further seizures.
VARIATIONS WITH TIME
Maturational changes
In many types of epilepsy, especially childhood epilepsy,
seizure types and EEG patterns are age dependent
(Fig. 4). Many epileptic syndromes are only seen in chil-
dren with striking age-dependent patterns that can evolve
or resolve over time (Dulac, 1994). It is also known that
the electro-clinical manifestations of seizures in newborns
are dierent to those during infancy and childhood, and
some types of seizures e.g. infantile spasms occur exclu-
sively during this early period of development. Normally, in
the rst two years of post-natal life there is over-production
of synapses. This is facilitated by the relatively slow
maturation of inhibitory neurotransmitter systems and
 R. A. B. Badawy et al. / Neuroscience 222 (2012) 8999
the rapid maturation of excitatory systems. This creates a
functional imbalance between excitatory and inhibitory
synaptic neurotransmission in the brain (Holmes, 1997).
In the immature brain the eects of excitatory neurotrans-
mitter systems predominate initially and then become less
predominant as inhibitory systems gradually mature
(Brooks-Kayal, 2005). The function of the GABA-ergic
system also diers markedly in the mature and immature
brain. Whereas GABAA receptor activation results in neu-
ronal hyperpolarization and an inhibition of cell ring in the
mature brain, receptor activation results in membrane
depolarization and excitation in the immature brain
(Brooks-Kayal, 2005). This is followed by a longer pro-
cess, lasting through mid-adolescence, where pruning of
excessive synapses and activity-dependent renement
of synaptic connections take place. The visual cortex
completes this process of pruning earlier than the motor
cortex (Huttenlocher and Dabholkar, 1997). Thus one of
the factors that may contribute to the increased suscepti-
bility of infants and young children to seizures is the imbal-
ance between excitation and inhibition in the immature
brain. While this imbalance is a transient and essential
component of normal brain maturation, it may be pro-
longed or even re-emerge later in development due to
various genetic, maturational or acquired factors (Holmes,
1997).
Idiopathic partial epilepsy especially benign childhood
epilepsy with centro-temporal spikes (BECTS) is consid-
ered to be disorders of abnormal brain maturation (Degen
Fig. 4. Time line showing distribution of age-specic epileptic syndromes according to age of onset.
95
and Degen, 1992). BECTS usually starts between four
and 11 years and almost all children achieve remission
by adolescence (Kramer et al., 1998). This includes chil-
dren whose seizures have been drug resistant.
Idiopathic generalized epilepsies on the other hand
are thought to mainly have a genetic basis (Helbig
et al., 2008). Genetically determined alterations in sodium
channel structure and function are widely described in
many IGEs. These include generalized epilepsy with feb-
rile seizures plus, severe myoclonic epilepsy of infancy
(SMEI), and benign familial neonatal-infantile seizures
(BFNIS) (Gardiner, 2005; Helbig et al., 2008). These are
strikingly dierent epileptic syndromes in terms of age of
onset, seizure type and severity, and developmental out-
come, the most benign being BFNIS and the most severe
being SMEI. Mutations in the genes encoding for the volt-
age-dependent potassium channels are described in
benign familial neonatal convulsions (Gardiner, 2005),
which is a rare, autosomal-dominant idiopathic epilepsy.
Seizures occur in well newborn infants from the second
or third day of life and usually remit by six weeks. Child-
hood absence epilepsy which comprises 8% of epilepsy
cases in school-aged (313 years) children, also shows
a striking age dependence with a third of the children
becoming seizure free by teenage while the rest either
develop GTCs or evolve into juvenile myoclonic epilepsy.
This pattern suggests that although an autosomal-
dominant pattern of inheritance with age-dependent pen-
etrance causing specic disturbances in ion channels
96 R. A. B. Badawy et al. / Neuroscience 222 (2012) 8999
(sodium and calcium) and GABAA receptors has been
described (Helbig et al., 2008), a multifactorial pattern that
involves both genetic and environmental factors is more
likely.
Other common disorders with striking age dependence
are the childhood epileptic encephalopathies. These
include many syndromes in which seizures typically start
to occur during the neonatal period such as early infantile
epileptic encephalopathy to those that start during early
childhood such as epilepsy with myoclonic-astatic sei-
zures. One such syndrome is LennoxGastaut syndrome
(LGS). Children with LGS characteristically present in early
childhood, either de novo or as an evolution of West syn-
drome (infantile spasms). Despite the homeogenity in the
electro-clinical presentation, this disorder is commonly
associated with a wide variety of diuse or multifocal
pathologic processes predominantly, although not exclu-
sively, involving cortical grey matter and subcortical struc-
tures (Markand, 2003).
Progression to chronic epilepsy
Whether or not epilepsy is a progressive disorder is a
matter for debate. There is strong animal evidence con-
rming progressive changes associated with epilepsy.
Prolonged and recurrent seizures in these models lead
to cell loss and subsequent reorganization of synaptic net-
works (Holmes, 2002). A common pathological nding in
patients with focal epilepsy characterized by complex par-
tial seizures is hippocampal sclerosis which consists of
gliosis and neuronal loss primarily in the hilar polymorphic
region and CA1 pyramidal region of the hippocampus,
with relative sparing of the CA2 pyramidal region and an
intermediate lesion in the CA3 pyramidal region and den-
tate granule cells. The available evidence suggests that
status epilepticus and chronic epilepsy with recurrent sei-
zures are associated with neuronal injury and reactive
changes in human and animal hippocampi such that hip-
pocampal sclerosis is generally considered an acquired
lesion (Holmes, 2002). Anecdotally, however, there are
examples of individuals who experienced frequent com-
plex partial and generalized seizures but in whom both
in vivo magnetic resonance imaging (MRI) and postmor-
tem neuropathologic examination were remarkable for
the normality of both hippocampus and neocortex, at least
using qualitative assessment (Holtkamp et al., 2004). This
underlines the heterogeneity of individual susceptibility to
neuronal damage from severe epilepsy, possibly from as
yet undened genetic factors.
Another commonly described abnormality associated
with seizures is mossy bre sprouting leading to formation
of recurrent excitatory collaterals, increasing the net excit-
atory drive of dentate granule neurons (Sutula et al.,
1988). Nevertheless, there is evidence in some animal
studies that sprouting can occur without the development
of spontaneous seizures (Cavalheiro et al., 1991) and that
seizures can occur with severe to complete loss of sprout-
ing (Longo and Mello, 1997). There are also reports of
increased number or modied properties of NMDA
receptors (McNamara and Routtenberg, 1995) as well
as reports of glutamatergic modulation of GABA-ergic sig-
nalling among neuronal populations in the epileptic hippo-
campus (Kullmann and Semyanov, 2002). But it remains
dicult to elucidate what changes are due to the actual
underlying pathology or a compensatory mechanism
associated with recurrent seizures over time.
In patients, it is well recognized that complex febrile
seizures early in life are associated with the later develop-
ment of temporal lobe epilepsy (Annegers et al., 1987).
This transition from a latent period to a seizure disorder
is strong evidence of progression of the disorder. In
addition to having increased seizure susceptibility, many
if not most MTLE patients become refractory by adoles-
cence or early adulthood (Engel, 1999) and are often
associated with co-morbidities such as cognitive decline
(Marques et al., 2007), which indicates that some change
is occurring in the brain. Furthermore, the number of pre-
treatment seizures was shown to be related to the proba-
bility of subsequent remission (Mohanraj and Brodie,
2006) and in the refractory patients, longer disease dura-
tion has been consistently associated with progressive
atrophy of mesio-temporal lobe structures including the
hippocampus and entorhinal cortex (Bernasconi and
Bernhardt, 2010). There is also evidence of an associa-
tion between the severity of hippocampal damage and
the estimated total seizure burden and seizure frequency
(Briellmann et al., 2002). In addition, progressive neocor-
tical atrophy has been observed in patients with intracta-
ble temporal lobe epilepsy and correlated with epilepsy
duration (Bernasconi and Bernhardt, 2010). Furthermore,
there is recent evidence of progressive changes in cortical
excitability described in a longitudinal transcranial mag-
netic stimulation study on refractory patients with dierent
forms of idiopathic generalized and focal epilepsies
(Badawy et al., 2010; Badawy et al., 2012).
Conversely, there is growing clinical evidence that in
most cases the occurrence of seizures itself does not inu-
ence the long-term outcome of epilepsy (Berg and
Shinnar, 1997; Marson et al., 2005). These studies
indicate that with the exception of some rare syndromes,
human epilepsy is not a progressive, self-perpetuating
disorder. Furthermore, there is evidence that the co-
morbidities such as cognitive problems remain relatively
stable over time even in patients with refractory seizures
(Holmes et al., 1998) suggesting that recurrent seizures
do not have a major eect on brain function. Clearly, more
human studies need to be performed to resolve this
controversy.
CONCLUSION
In this review we have highlighted the complex and highly
variable patterns of cortical excitability in patients with epi-
lepsy. As summarized in Fig. 5, changes in excitability
can be a result of many factors however; it is a unifying
theme in almost all epilepsies. Bursting behaviour in neu-
rons may arise from a seemingly continuum of multiple
parameters (Marten et al., 2009), thus homoeostatic and
compensatory mechanisms may play an important role.
In order to understand this and the mechanisms behind
the highly variable nature of cortical excitability one must
measure a comprehensive suite of physiological parame-
ters simultaneously. Finding a correlation between a
 R. A. B. Badawy et al. / Neuroscience 222 (2012) 8999
Fig. 5. Schematic illustrating the dierent states of an epileptic brain and the dierent physiological factors that inuence cortical excitability during
those state.
diseased state and a change in a single physiological var-
iable cannot provide a complete solution in bridging our
understanding. In addition, due to the heterogeneity of
epilepsies and diversities of possible mechanisms, a pa-
tient-specic approach must be taken to facilitate our con-
ception of these ever-changing states of cortical
excitability to form new and robust treatment strategies.
DISCLOSURE
None of the authors have any conict of interest to
disclose.
AcknowledgmentsThe authors wish to thank Dr. Danny Flana-
gan and Mr. Simon Vogrin, for their insightful suggestions during
the preparation of this manuscript and help with the gures.
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