What is a seizure network? Long-range network consequences of focal seizures

What defines the spatial and temporal boundaries of seizure activity in brain networks? To fully answer this question a precise and quantitative definition of seizures is needed, which unfortunately remains elusive. Nevertheless, it is possible to ask under conditions where clearly divergent patterns of activity occur in large-scale brain networks whether certain activity patterns are part of the seizure while others are not. Here we examine brain network activity during focal limbic seizures, including diverse regions such as the hippocampus, subcortical arousal systems and fronto-parietal association cortex. Based on work from patients and from animal models we describe a characteristic pattern of intense increases in neuronal firing, cerebral blood flow, cerebral blood volume, blood oxygen level dependent functional magnetic resonance imaging (BOLD fMRI) signals and cerebral metabolic rate of oxygen consumption in the hippocampus during focal limbic seizures. Similar increases are seen in certain closely linked subcortical structures such as the lateral septal nuclei and anterior hypothalamus, which contain inhibitory neurons. In marked contrast, decreases in all of these parameters are seen in the subcortical arousal systems of the upper brainstem and intralaminar thalamus, as well as in the fronto-parietal association cortex. We propose that the seizure proper can be defined as regions showing intense increases, while those areas showing opposite changes are inhibited by the seizure network and constitute long-range network consequences beyond the seizure itself. Importantly, the fronto-parietal cortex shows sleep-like slow wave activity and depressed metabolism under these conditions, associated with impaired consciousness. Understanding which brain networks are directly involved in seizures versus which sustain secondary consequences can provide new insights into the mechanisms of brain dysfunction in epilepsy, hopefully leading to innovative treatment approaches.