Autonomic reflex plasticity associates with time-dependent SUDEP susceptibility in a murine model with hyperactive stress circuits

Reviewer #1 (Public review):

Summary:

The manuscript entitled "Autonomic reflex plasticity associates with time-dependent SUDEP susceptibility in a murine model with hyperactive stress circuits" by Dr. Saunders and colleagues combined a traditional mouse model of SUDEP, ventral intrahippocampal kainite (vIHKA) injection, with a genetic model of chronic hyperactivity of central corticotropin-releasing hormone (CRH) neurons (Kcc2/Crh) that further increases the risk of SUDEP in the weeks following seizure.

Strengths:

Their results show during spontaneous seizures Kcc2/Crh mice had more pronounced reflex-like ictal bradycardias compared to WT controls that notably occurred prior (~10 sec) to seizure termination and had greater autonomic disturbances compared to WT controls, including a pronounced serotonin-mediated Bezold Jarisch reflex. These results show chronic hyperactivity of central corticotropin-releasing hormone (CRH) neurons (Kcc2/Crh) increased autonomic disturbances and risk of SUDEP in a kainic acid model of epilepsy.

Weaknesses:

This study could be improved with a more thorough assessment of heart rate, blood pressure and breathing during and following the seizures, and in particular the fatal event. It is unclear if the bradycardias were spontaneous or a result of preceding central or obstructive apneas, oxygen desaturations, hypercapnia, arrhythmias, or other possible triggers.

Considerable prior work in the literature suggests SUDEP could be mediated, in some patients, by a burst of parasympathetic activity to the heart. Were the heart rate changes in these animals during seizures inhibited or blocked by atropine or atenolol?
The injection of the 5HT agonist phenylbiguanide into the right jugular is not a selective approach for activating the Bezold Jarisch Reflex (BJR), which is caused by increased activity of intracardiac sensory neurons (generally activated with ischemia or a combination of low preload with high contractility). The results should be interpreted more cautiously, as a response to systemic administration of phenylbiguanide only.

Reviewer #2 (Public review):

Summary:

In this manuscript, the authors set out to evaluate the role of hypothalamic pituitary axis hyperactivity on cardiac and autonomic changes during epileptogenesis and following seizures in a mouse model of temporal lobe epilepsy. Epilepsy is very common. It can frequently result in death from sudden unexpected death in epilepsy, or SUDEP. SUDEP is thought to be at least in part due to seizure-related cardiac and autonomic instability. Increased stress states are well known to be comorbid with epilepsy. This comorbidity is thought to increase the risk of SUDEP. Here, the authors hypothesized that a mouse model of heightened stress in which there is hyperactivity of the CRH neurons in the hypothalamus would demonstrate exaggerated cardiac and autonomic effects of seizures and epilepsy.

Strengths:

For the chronic stress model, they employed the Kcc2/Crh mice that have a genetic deletion of the potassium chloride cotransporter in CRH neurons. They treated these mice and their wild-type littermates with intra-hippocampal kainic acid or saline, as epileptic and sham-treated animals, respectively. The assessed cardiac activity, blood pressure, baroreflex, and the Bezold-Jerisch reflex during epileptogenesis. This, in general, is an interesting study. They make some interesting and potentially important observations regarding heart rate and blood pressure in seizures and epilepsy.

Weaknesses:

Some of the conclusions may be a bit overstated as is and would benefit from more discussion and perhaps additional data.