Mutations in the KCNT1 (Slack, K_Na1.1) sodium-activated potassium channel produce severe epileptic encephalopathies. Expression in heterologous systems has shown that the disease-causing mutations give rise to channels that have increased current amplitude. It is not known, however, whether such gain of function occurs in human neurons, nor whether such increased K_Na current is expected to suppress or increase the excitability of cortical neurons. Using genetically engineered human induced pluripotent stem cell (iPSC)-derived neurons, we have now found that sodium-dependent potassium currents are increased several-fold in neurons bearing a homozygous P924L mutation. In current-clamp recordings, the increased K_Na current in neurons with the P924L mutation acts to shorten the duration of action potentials and to increase the amplitude of the afterhyperpolarization that follows each action potential. Strikingly, the number of action potentials that were evoked by depolarizing currents as well as maximal firing rates were increased in neurons expressing the mutant channel. In networks of spontaneously active neurons, the mean firing rate, the occurrence of rapid bursts of action potentials, and the intensity of firing during the burst were all increased in neurons with the P924L Slack mutation. The feasibility of an increased K_Na current to increase firing rates independent of any compensatory changes was validated by numerical simulations. Our findings indicate that gain-of-function in Slack K_Na channels causes hyperexcitability in both isolated neurons and in neural networks and occurs by a cell-autonomous mechanism that does not require network interactions. SIGNIFICANCE STATEMENTKCNT1 mutations lead to severe epileptic encephalopathies for which there are no effective treatments. This study is the first demonstration that a KCNT1 mutation increases the Slack current in neurons. It also provides the first explanation for how this increased potassium current induces hyperexcitability, which could be the underlining factor causing seizures.

Vestibular hair cells transmit information about head position and motion across synapses to primary afferent neurons. At some of these synapses, the afferent neuron envelopes the hair cell, forming an enlarged synaptic terminal called a calyx. The vestibular hair cell–calyx synapse supports a mysterious form of electrical transmission that does not involve gap junctions, termed nonquantal transmission (NQT). The NQT mechanism is thought to involve the flow of ions from the presynaptic hair cell to the postsynaptic calyx through low-voltage-activated channels driven by changes in cleft [K ⁺ ] as K ⁺ exits the hair cell. However, this hypothesis has not been tested with a quantitative model and the possible role of an electrical potential in the cleft has remained speculative. Here, we present a computational model that captures experimental observations of NQT and identifies features that support the existence of an electrical potential ( ϕ ) in the synaptic cleft. We show that changes in cleft ϕ reduce transmission latency and illustrate the relative contributions of both cleft [K ⁺ ] and ϕ to the gain and phase of NQT. We further demonstrate that the magnitude and speed of NQT depend on calyx morphology and that increasing calyx height reduces action potential latency in the calyx afferent. These predictions are consistent with the idea that the calyx evolved to enhance NQT and speed up vestibular signals that drive neural circuits controlling gaze, balance, and orientation.

Objective: Brain‐responsive neurostimulation (RNS System, NeuroPace) is used to treat medically refractory focal epilepsy and also provides long‐term ambulatory neurophysiologic data. We sought to determine whether these data could predict the clinical response to antiseizure drugs (ASDs).Methods: First, newly added medications were identified in RNS System patients followed at a single epilepsy center. Daily detection rates including “episode starts” (predominantly interictal activity) and “long episodes” (often electrographic seizures) were compared before and after ASD initiation. Efficacy was determined from documentation of clinical improvement and medication retention. Next, the analysis was repeated on an independent sample of patients from a multicenter long‐term treatment trial, using an efficacy measure of ≥50% reduction in diary‐recorded seizure frequency after 3 months.Results: In the single center cohort, long episodes, but not episode starts, had a significantly greater reduction in the first week for clinically efficacious compared to inefficacious medications. In this cohort, having no long episodes in the first week was highly predictive of ASD efficacy. In the multicenter cohort, both long episodes and episode starts had a significantly greater reduction for effective medications starting in the first 1‐2 weeks. In this larger dataset, a ≥50% decrease in episode starts was 90% specific for efficacy with a positive predictive value (PPV) of 67%, and a ≥84% decrease in long episodes was 80% specific with a PPV of 48%. Conversely, a <25% decrease in long episodes (including any increase) or a 80%.Significance: In RNS System patients with stable detection settings, when new ASDs are started, detection rates within the first 1‐2 weeks may provide an early, objective indication of efficacy. These data could be used to identify responses to medication trials early to allow more rapid medication adjustments than conventionally possible.

Gain-of-function mutations in KCNT1, the gene encoding Slack (K_Na1.1) channels, result in epilepsy of infancy with migrating focal seizures (EIMFS) and several other forms of epilepsy associated with severe intellectual disability. We have generated a mouse model of this condition by replacing the wild type gene with one encoding Kcnt1^R455H, a cytoplasmic C-terminal mutation homologous to a human R474H variant that results in EIMFS. We compared behavior patterns and seizure activity in these mice with those of wild type mice and Kcnt1^−/− mice. Complete loss of Kcnt1 produced deficits in open field behavior and motor skill learning. Although their thresholds for electrically and chemically induced seizures were similar to those of wild type animals, Kcnt1^−/− mice were significantly protected from death after maximum electroshock-induced seizures. In contrast, homozygous Kcnt1^R455H/R455H mice were embryonic lethal. Video-EEG monitoring of heterozygous Kcnt1^+/R455H animals revealed persistent interictal spikes, spontaneous seizures and a substantially decreased threshold for pentylenetetrazole-induced seizures. Surprisingly, Kcnt1^+/R455H mice were not impaired in tasks of exploratory behavior or procedural motor learning. These findings provide an animal model for EIMFS and suggest that Slack channels are required for the development of procedural learning and of pathways that link cortical seizures to other regions required for animal survival.

The function of long-term memory is not just to reminisce about the past, but also to make predictions that help us behave appropriately and efficiently in the future. This predictive function of memory provides a new perspective on the classic question from memory research of why we remember some things but not others. If prediction is a key outcome of memory, then the extent to which an item generates a prediction signifies that this information already exists in memory and need not be encoded. We tested this principle using human intracranial EEG as a time-resolved method to quantify prediction in visual cortex during a statistical learning task and link the strength of these predictions to subsequent episodic memory behavior. Epilepsy patients of both sexes viewed rapid streams of scenes, some of which contained regularities that allowed the category of the next scene to be predicted. We verified that statistical learning occurred using neural frequency tagging and measured category prediction with multivariate pattern analysis. Although neural prediction was robust overall, this was driven entirely by predictive items that were subsequently forgotten. Such interference provides a mechanism by which prediction can regulate memory formation to prioritize encoding of information that could help learn new predictive relationships.SIGNIFICANCE STATEMENTWhen faced with a new experience, we are rarely at a loss for what to do. Rather, because many aspects of the world are stable over time, we rely on past experiences to generate expectations that guide behavior. Here we show that these expectations during a new experience come at the expense of memory for that experience. From intracranial recordings of visual cortex, we decoded what humans expected to see next in a series of photographs based on patterns of neural activity. Photographs that generated strong neural expectations were more likely to be forgotten in a later behavioral memory test. Prioritizing the storage of experiences that currently lead to weak expectations could help improve these expectations in future encounters.

To prospectively investigate the utility of seizure induction using systematic 1Hz stimulation by exploring its concordance with the spontaneous seizure onset zone (SOZ) and relation to surgical outcome; comparison with seizures induced by non-systematic 50 Hz stimulation was attempted as well. Prospective cohort study from 2018-2021 with ≥ 1y post-surgery follow up at Yale New Haven Hospital. With 1 Hz, all or most of the gray matter contacts were stimulated at 1, 5, and 10 mA for 30-60s. With 50 Hz, selected gray matter contacts outside of the medial temporal regions were stimulated at 1-5 mA for 0.5-3s. Stimulation was bipolar, biphasic with 0.3 ms pulse width. The Yale Brain Atlas was used for data visualization. Variables were analyzed using Fisher's exact, χ², or Mann-Whitney test. Forty-one consecutive patients with refractory epilepsy undergoing intracranial EEG for localization of SOZ were included. Fifty-six percent (23/41) of patients undergoing 1 Hz stimulation had seizures induced, 83% (19/23) habitual (clinically and electrographically). Eighty two percent (23/28) of patients undergoing 50 Hz stimulation had seizures, 65% (15/23) habitual. Stimulation of medial temporal or insular regions with 1 Hz was more likely to induce seizures compared to other regions [15/32 (47%) vs. 2/41 (5%), p < 0.001]. Sixteen patients underwent resection; 11/16 were seizure free at one year and all 11 had habitual seizures induced by 1 Hz; 5/16 were not seizure free at one year and none of those 5 had seizures with 1 Hz (11/11 vs 0/5, p < 0.0001). No patients had convulsions with 1 Hz stimulation, but four did with 50 Hz (0/41 vs. 4/28, p = 0.02). Induction of habitual seizures with 1 Hz stimulation can reliably identify the SOZ, correlates with excellent surgical outcome if that area is resected, and may be superior (and safer) than 50 Hz for this purpose. However, seizure induction with 1 Hz was infrequent outside of the medial temporal and insular regions in this study.