Jan-Mar
, 2019
September
06, 2021
Epilepsy is a progressive and disabling disease if not diagnosed early; for this reason, it has been the subject of research, specially in cases with idiopathic etiology. Approximately between 1 and 2% of the world population have epilepsy. In Mexico the prevalence is from 10 to 20 patients per 1000 inhabitants. Lately, the scientific community has been trying to create, adapt, and use biomolecular tools to study its pathophysiology so that, hopefully, in a near future we are able to intervene in the natural history of this disease. The aim of this work is to cite evidence about some of the molecular biology techniques in order to support and encourage investment in neurogenomical research; as a necessary tool in the study of epilepsy.
Key words:
Epilepsy, Biomolecular Tools, Neurogenomics
The International League Against Epilepsy (ILAE) defines an epileptic seizure as the occurrence of signs and/or symptoms due to an excessive synchronous or asynchronous abnormal neuronal activity, and epilepsy as a disease characterized by the long-term predisposition to generate epileptic seizures, as well as, by the neurobiological, cognitive, psychological, and social consequences of this condition1.
In the world, there are >50 million people suffering from epilepsy, of which 80% live in developing countries with a prevalence of 7-14 per 1000 inhabitants, unlike the developed countries with a proportion of 4-10 per 1000 habitants2.
In Mexico, a prevalence of 10-20 per 1000 habitants has been found; therefore, it can be estimated that there are approximately 1-2 million Mexicans affected3.
Etiologically, epilepsy can be classified into the following groups: symptomatic or secondary (where there is a known cause, such as tumor, neuroinfection, and congenital brain malformation), idiopathic (when genetic factors are suspected, inherited, or de novo, etc.), and cryptogenic (type of epilepsy in which it cannot be associated to a certain cause)4. Around 20-30% of epilepsies are caused by acquired conditions and 70-80% are related to one or more genetic factors5.
Epilepsy is considered a public health problem, due to its high morbidity and psychosocial repercussions (stigmatization or rejection) and economic (unemployment, pharmacological, and hospitalization expenses); therefore, it should be a reason for interest, investment, and research to understand the disease and provide the best care to this sector of the population. Considering the proportion of epilepsy related to genetic factors, 5 it is crucial to know the clinical, physiological, and genomic tools used in the diagnosis in this type of patients.
Since the publication in 1951 in JAMA by the epileptologist William G. Lennox, it was possible to confirm the importance of the genetic causes in some types of epilepsy, observed in their studies in twins6. Later, Watson and Crick (1953) propose the helical structure, antiparallel, and complementary to DNA7, researchers have used these principles for the development of molecular technology to understand and analyze the genetic material of all kinds of organisms, including humans, interest in the study of inheritance and genes, using genomics (a discipline that deals with the study of genomes, genes, and their functions, as well as related biotechnological techniques)8.
Advances in genomic technology are providing tools for the study of genetic factors that may be involved with different types of epilepsy. Some of the main types of studies used in epilepsy research are described below: full genome-wide association studies (GWAS), sequencing, next-generation sequencing (NGS), sequencing of whole genome (whole genome sequencing/[WGS]), complete exome sequencing (whole exome sequencing/[WES]), chromosomal microarrays (RNA and DNA microarrays) by comparative genomic hybridization (CGH) to detect copy number variations (CNVs), insertions and deletions, single-nucleotide polymorphisms (SNPs), or point mutations, (Fig. 1).
In genetic epidemiology, a complete genome association study (GWA) uses high-throughput technologies to analyze hundreds of thousands of SNPs (SNPs, generally referring to a single-base variant in the human genome) and relates them to measurable traits, as well as with various clinical conditions. These are studies designed to identify common genetic variants between two or more populations that contribute to a risk of disease9.
As an example, in 2014, the ILAE published a meta-analysis of 12 cohorts where they performed a complete genome association on 8696 patients with epilepsy and 26,157 controls. They found association of risk in the loci 2q24.3 (p=8.71×10−10) that involves the gene SCN1A and in the loci 4p15.1 (p=5 44×10−9) that involves the PCDH7 gene in patients with focal and generalized epilepsy. For patients with generalized epilepsy at the 2p16.1 loci (p=9.99×10−9), which implicate the VRK2 or FANCL genes, they could not determine an SNP with statistical significance related to focal epilepsy10. Feenstra et al.11 studied through GWA children with febrile seizures as an adverse effect after the administration of the triple viral vaccine (rubella, measles, and mumps), children who did not have febrile seizures after the vaccine and finally children without a history of febrile seizures as controls. They found two risk loci related to febrile seizures after vaccination rs273259 (p=5.9×10−12 and p=1.2×10−9) involving the gene IFI44L and rs1318653 (p=9.6×10−11 and p=1.6×10−9) that involves the CD46 gene, with p values against the controls and against children who did not have febrile seizures after the vaccine, respectively. On the other hand, they found four risk loci for febrile seizures, in general, two were in known genes related to epilepsy (SCN1A and SCN2A).
CNVs are defined as a DNA segment equal to or >1 kb whose number of copies is variable (duplicated or deleted) when compared to a reference genome (Fig. 2).
CNVs are an important source of normal genetic variation (in a frequency >1%), but some may participate as risk factors or causes of disease5,12. CNVs can be detected with DNA microarrays by means of CGH, array CGH, (Fig. 3)
Some rare CNVs (frequency <1%) involve genes from known diseases and may be related to 5-10% in cases of childhood epilepsy13,14. Helbig et al. reported the role of CNVs in patients with epilepsy, finding 88 rare NVs in 71 patients (31.8%) >100 kb related to the disease15.
In general, research in generalized and focal epilepsy has identified recurrent microdeletions in up to 3% of patients with idiopathic generalized epilepsy and 1% focal epilepsy. The microdeletions in the chromosomal regions 15q13.3 and 16p13.11 are the most frequently identified variants16,17.
DNA sequencing refers to the determination of the order of the nucleotides of a given sequence, from some base pairs (bp) to the sequence of complete genomes. The NGS, also called mass sequencing in parallel, means that millions of small DNA fragments (around 100 bp) can be sequenced at the same time18.
At present, two types of sequencing are performed for the study of epilepsy: complete genome sequencing and complete exome sequencing (Fig. 3).
It refers to the determination of the order of the nucleotides of the whole genome (both the coding and non-coding sequences) which covers around 3000 million bp19.
This technique allows exploring 180,000 exons or coding regions (more or less 30 million bp), which corresponds to approximately 1% of the human genome20, it is estimated that 85% of the variations related to hereditary diseases are found in the exome18.
Helbig et al. evaluated the performance of exome sequencing as a diagnostic method in patients with epilepsy, finding 38.2% positive results compared to controls with p=0.004 value, concluding that this technique is a useful diagnostic tool, especially in severe epilepsy of early onset21.
In the past 10 years, the advancement of complete genome sequencing or exome techniques has allowed the identification of new genes and genetic variants involved in family epilepsies, severe epilepsies, and epileptic encephalopathies, which has had an important impact in the diagnosis of this disease. The current rate in the diagnosis of epilepsy by NGS ranges from 20% to 30% and specifically with WES is approximately 25%22.
Some of the major genes involved in generalized epilepsy are described below:
SCN1A codes for the alpha-1 subunit of the voltage-dependent sodium channel. The transmembrane alpha subunit forms the central pore of the channel. This ion channel is critical for the generation and propagation of action potentials. The channel responds to the voltage difference across the cell membrane to create a pore that allows sodium ions to pass through the membrane. The influx of sodium creates an action potential, which is critical for signaling within the brain. Mutations of loss of function cause a reduction of sodium currents and alteration of the signaling of the hippocampal GABAergic interneurons. Allelic variants of this gene are associated with generalized epilepsy with febrile seizures and epileptic encephalopathy. In 70-90% of cases, Dravet syndrome is caused by a de novo mutation in SCN1A, which often leads to a non-functional protein23,24.
SCN2A encodes the alpha-II subunit of the voltage-dependent sodium channel and is found in the initial segment of the axon, nonsense mutations are observed in patients with epileptic encephalopathies where their expression is reduced on the cell surface, resulting in a net loss of function. This mutation is related to four different phenotypes such as benign neonatal and infantile epilepsy, autism and intellectual disability, infantile spasms, and early-onset epileptic encephalopathies including Ohtahara syndrome and severe neonatal epilepsy. All phenotypes within the SCN2A spectrum include cognitive disturbances, seizures, and movement disorders23,24.
CACNA1A codes for the alpha-1 subunit of voltage-dependent calcium channels and mediates the entry of calcium ions into excitable cells; it is also included calcium-dependent processes including muscle contraction, hormone release, and neurotransmitter release. Mutations in this gene are related to episodic ataxias, spinocerebellar degeneration, and familial hemiplegic migraine, generalized epilepsies such as absences or Dravet syndrome, and tonic paroxysms23,24.
Regarding focal epilepsy, the main candidate genes are described below:
GRIN2A encodes the alpha-2 subunit of the glutamate receptor N-methyl-D-aspartate, it is involved in long-term potentiation, an activity-dependent increase in the efficiency of synaptic transmission; the interruption of this gene is associated with the disorder of focal rolandic epilepsy, atypical benign partial epilepsy, Landau-Kleffner syndrome, and some learning disorders23,24.
DEPDC5 codes for a member of the IML1 family of proteins involved in G-protein signaling pathways (mTORC1) and regulates cell growth by detecting nutrient availability; inhibition of mTOR can cause cortical dysplasia at variable sites. Mutations in this gene have been related to focal epilepsy of variable foci, nocturnal frontal lobe dominant epilepsy, and temporal mesial lobe family epilepsy23,24.
LGI1 gene codes for a member of the superfamily of proteins rich in leucine (glioma rich in inactivated leucine), can regulate the activity of voltage-dependent potassium channels, and is involved in the regulation of neuronal growth and cell survival. This gene is rearranged as the result of translocations in glioblastoma cell lines. Mutations in this gene are related to lateral temporal epilepsy23,24.
The discovery of mutations in specific genes (encoders for ion channels expressed in brain neurons, neurotransmitter receptors, or molecules with assumed functions in intercellular communication) has allowed to corroborate the suspicions that the physiopathological bases of this disease seem to be related with alterations in the electrical type processes, especially those that cause alterations in the stability of the membranes25,26.
The table summarizes some of the candidate genes related to epilepsy, discovered by sequencing, association studies, DNA microarrays, etc. (Supplementary Table 1).
One of the main goals in the molecular research of epilepsy is to provide personalized treatment, and some data are beginning to emerge that this may be possible, in 2014, the abnormal gain of the function of the KCNQ1 gene that codes for member 1 of the Q subfamily of potassium channels dependent on filtration and reverts with quinidine27. On the other hand, personalized therapy with memantine or topiramate was also proposed in two patients with early-onset epileptic encephalopathy with mutation in the GRIN2A gene28.
It is important to take into account the genetic factors related to the disease when deciding the treatment of the patient, especially if the treatment is a surgical procedure. Skjei et al. published a series of cases in which they describe the clinical and histopathological characteristics in six patients with refractory epilepsy and mutations in the SCN1A gene undergoing focal cortical resection. In all cases, patients were refractory to the surgical procedure; it was observed mild diffuse malformations of cortical development in four of six patients concluding that cortical resection may not be effective in patients with this mutation and with the neuropathological changes mentioned29.
New approaches for the treatment of epilepsy are under development, experimental research based on viral vectors, genetic opto tools involving the use of light at wavelengths of 280-570 nm, to control the activity of ion channels in rhodopsin and halorhodopsin in hippocampal neurons, dentate gyrus, and cerebellum, which activate or inhibit a neuron and even several conglomerates of neuronal networks that allow a control of neuronal electrical activity and cell graft techniques in animal models; all of them are new techniques used for a future to prevent the disease or to provide the best treatment to this type of patients30,31.
Epilepsy is considered a disease of complex inheritance, the main difficulties associated with the study of complex diseases are incomplete penetrance, genetic heterogeneity, and polygenic (or multifactorial) inheritance32. Therefore, it is not yet clear what is the role of inheritance and other genetic factors in epileptogenesis. There is currently a project called Phenotype/Epilepsy Genotype EPGP: the Epilepsy Phenome/Genome Project; it is a large-scale project involving 27 centers in the United States, Australia, Argentina and Canada with the aims of analyzing the detailed phenotype of patients, determining the genotype and discovering new genes. Genetics and genomics in epilepsy is an open field of research that has had a great break in the last 15 years, which has solved many of the cases that were previously classified as of unknown cause, however, there is still a long way to go.
Gen | Proteina | Localización | Tipo | Alteración | Fenotipo | Técnica | Fuentes |
---|---|---|---|---|---|---|---|
ALG13 | Asparagine-linked glycosylation 13, S. cerevisiae, homolog of glycosyltransferase 28 domain-containing 1 | Xq23 | SNP | - LYS94GLU |
EETI, EI | WES | De Ligt et al., 20121 |
ARHGEF9 | Rho guanine nucleotide exchange factor 9 (Collybistin) | Xq11 | SNP | - GLY55ALA |
EIEE | Array CGH | Harvey et al., 20047 |
ARX | Aristaless-related homeobox, X-Linked | Xp21.3 | Dup |
- 24-BP DUP, NT428 |
EEIT | CGH |
Bruyere et al., 199911
|
CACNA1A | Subunidad alpha-1-a de canal P/Q de calcio dependiente de voltaje | 19p13.13 | SNP | - ARG1820TER | Aus, EGI | WES |
Chan et al., 200823
|
CACNA1H | Calcium channel, voltage-dependent, T type, alpha 1H subunit | 16p13.3 | SNP | - PHE161LEU |
Aus, EGI | DES |
Chen et al., 200328
|
CACNA2D1 | Calcium channel, voltage-dependent. alpha2/delta subunit 1 | 7q11-q21 | Del | - 7.5-MB deletion 7q21.11-q21.12 |
ESG | GWEF Array CGH | Mefford et al., 201133
|
CDKL5 | Cyclin-dependent kinase-like 5 | Xp22.13 | Del SNP | - 1-BP DEL, 183T |
EEIT, EI, EMT | WES |
Archer et al., 200635
|
CHD2 | Chromodomain helicase DNA-binding protein 2 | 15q26.1 | Del |
- 1-BP DEL, 1809G GLU1412GLYFSTER64 |
Síndrome de Dravet, Lennox-Gastaut y Doose. (Fotosensible) EMA, Aus | WES, Targeted sequencing | Carvill et al., 2013,50
|
CHRNA7 | Cholinergic receptor, nicotinic, alpha 7 | 15q13.3 | Del | EGG | GWAS |
Dibbens et al., 200959
|
|
CNTNAP2 | Contactin-associated protein-like 2 | 7q35 | Del | 1-BP DEL, 3709G | EF con regresión. Síndrome Epilepsia Focal-Displasia Cortical | GWEF array CGH Targeted sequencing | Mefford et al., 201133
|
CSTB | Cystatin-B | 21q22.3 | Del SNP | - IVS1, G-C, -1 |
Epilepsia mioclónica progresiva (Síndrome de Unverricht-Lundborg) | Complete sequencing of the gene | Alakurtti et al., 200563
|
DEPDC5 | Dominio DEP 5 | 22q12.3 | Del |
- TYR7TER |
EFFFM, ELFNAD, ELTMF | WES, Direct sequencing | Baulac et al., 201572
|
DMRT2, DMRT3 | Doublesex- and Mab-3-related transcription factor 2 and factor 3 | 9p24.3 | Del | EI | Array - CGH | Epi4K Consortium and Epilepsy Phenome/Genome Project, 201584 | |
DNM1 | Dynamin 1 | 9q34.11 | SNP | ALA177PRO |
EEIT (Lennox-Gastaut), EI | WES | Møller, 20155
|
DOCK7 | Dedicator for cytokinesis 7 | 1p31.3 | Del |
- 1-BP DEL, 2510A |
EEIT | WES | Perrault et al., 201489 |
GABRA1 | Gamma-aminobutyric acid (GABA) A receptor, alpha 1 | 5q34 | SNP |
- ALA322ASP |
EEIT, EMJ, Aus | Array - CGH |
Carvill et al., 201490
|
GABRB3 | Gamma-aminobutyric acid A receptor, beta 3 | 15q11 | SNP | - PRO11SER |
EI, TCG, T, atonicas, Aus | Array - CGH |
Epi4K Consortium and Epilepsy Phenome/Genome
Project, 201584
|
GABRG2 | Receptor GABA-A, Polipéptido gamma-2 | 5q34 | SNP | - LYS289MET |
EGI, CF, Aus | Candidate gene sequencing | Audenaert et al., 200697
|
GNAO1 | Guanine nucleotide-binding protein alpha activating | 16q12.2 | SNP |
- ILE279ASN |
EEIT | CGH |
Lesca, 20159
|
GRIN2A | Glutamate receptor, ionotropic, N-methyl D-aspartate 2A | 16p13.2 | SNP | GLN218TER IVS4DS, G-A, +1 ASN615LYS LEU649VAL PRO522ARG MET1THR THR531MET IVS5AS, A-G, -2 ARG518HIS PHE652VAL ARG681TER TYR943TER | SEA, EF | WES | Møller, 20155
|
HCN1 | Hyperpolarization-activated cyclic nucleotide-gated potassium channel 1 | 5p12 | SNP | ASP401HIS |
EEIT | CGH |
Lesca, 20159
|
HDAC4 | Histone deacetylase 4 | 2q37.3 | EEIT | WES | Møller, 20155 | ||
HIP1 | Huntingtin interacting Protein 1 | 7q11 | EI | Array - CGH | Epi4K Consortium and Epilepsy Phenome/Genome Project, 201584 | ||
KCNQ2 | Potassium channel, voltage-gated, KQT-like subfamily, member 2 | 20q13.3 | SNP |
TYR284CYS |
EEIT, ENFB | CGH |
Lesca, 20159
|
KCNT1 | Potassium channel, sodium-activated subfamily T, member 1 | 9q34.4 | SNP | ARG428GLN |
ELFNAD, EICFM | WES | Barcia et al., 2012129
|
LGI1 | Leucine-rich gene, glioma inactivated 1 | 10q23.33 | SNP |
GLU383ALA |
ELTMF | Direct sequencing CNV analysis | Chabrol et al., 2007135
|
PCDH19 | Protocadherin 19 | Xq22.1 | SNP |
1-BP INS, 1091C |
EEIT en mujeres (Ohtahara, Dravet) | Microarrays, Systematic resequencing | Depienne et al., 2009143
|
PLCB1 | Phospholipase C, beta-1 | 20p12.3 | Del | 0.5-MB DEL | EEIT, CPMMI | CGH Genome-wide scan | Lesca, 20159
|
PNKP | Polynucleotide kinase 3 phosphatase | 19q13.33 | SNP |
GLU326LYS |
EEIT, Microcefalia-Crisis y Retraso Mental | CGH Genome-wide scan | Lesca, 20159
|
PRRT2 | Proline-rich transmembrane protein 2 | 16p11.2 | Dup |
1-BP DUP, 649C |
CIF, CICA | WES | Møller, 20155
|
RYR3 | Ryanodine receptor 3 | 15q13.3 | EEIT | WES | Møller, 20155 | ||
SCN1A | Sodium voltage-gated channel alpha subunit 1 | 2q24.3 | SNP |
ARG1648HIS |
Síndrome de Dravet, CF familiares, EEIT | WES |
Abou-Khalil et al., 2001159
|
SCN2A | Sodium channel, voltage-gated, type II, alpha subunit | 2q24.3 | ARG188TRP |
EEIT | Direct sequencing, WES, Genome-wide analysis. | Berkovic et al., 2004177
|
|
SCN8A | Sodium Channel, voltage-gated, type VIII, alpha subunit | 12q13.13 | SNP | ASN1768ASP |
EEIT |
WES |
Blanchard et al., 2015184
|
SLC2A1 | Solute carrier family 2 (facilitated glucose transporter), member 1 | 1p34.2 | SNP | ARG232CYS |
EGI | Direct sequencing, PCR sequencing | Arsov et al., 2012187
|
SLC25A22 | Solute carrier family 25 (mitochondrial carrier, glutamate) member 22 | 11p15.5 | SNP | PRO206LEU |
EEIT | CGH |
Lesca, 20159
|
SLC26A1 | Solute carrier family 26, (anion exchanger), member 1 | 4p16 | SEA | GWEF array CGH | Mefford et al., 201130 | ||
SLC35A2 | Solute carrier family 35 (UDP-galactose transporter) member 2 | Xp11.23 | Del SNP | 2-BP DEL, 433TA |
EEIT | CGH |
Lesca, 20159
|
SPTAN1 | Alpha, non-erythrocytic, spectrin 1 | 9q34.11 | Del Dup | 3-BP DEL, 6619GAG |
EEIT | CGH |
Lesca, 20159
|
STXBP1 | Syntaxin-binding protein 1 | 9q34.11 | SNP | GLY544ASP |
EIEE | WES | Møller, 20155
|
STX1B | Syntaxin 1B | 16p11.2 | Síndromes asociados con epilepsia febril | WES | Møller, 20155 | ||
ST3GAL3 | ST3 beta-galactoside alpha-2,3-sialyltransferase 3 | 1p34.1 | SNP | ALA320PRO | EEIT | CGH |
Lesca, 20159
|
SYNGAP1 | Synaptic RAS-GTPase-activating protein 1 | 6p21.32 | SNP | PRO562LEU |
EEIT, mioclónicas, Aus | WES | Barryer et al., 2013198
|
SZT2 | Seizure threshold 2, mouse homolog | 1p34.2 | SNP | ARG25TER |
EEIT | CGH |
Basel-Vanagaite et al., 2013200
|
TAS2R1, FAM173B, CCT5, MTRR | Taste receptor, type 2, member 1/family with sequence similarity 173, member B/chemokine receptor 5/5- methyltetrahydrofolate-homocysteine methyltransferase reductase | 5p15 | FS, focal, TCG, aA, SE | Array - CGH | Epi4K Consortium and Epilepsy Phenome/Genome Project, 201584 | ||
TBC1D24 | TBC1 domain family, member 24 | 16p13.3 | SNP |
ASP147HIS |
EEIT, EMIF | CGH |
Lesca, 20159
|
UBE3A | Ubiquitin protein ligase E3A | 15q11 | Del | EMA | GWEF array CGH | Mefford et al., 201133 |