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Cerebrospinal fluid GABA levels in involuntary movement disorders
Bruin Resecrrch Bulletin,
Vol. 5,
Suppl.2, pp.741-745.
Printed
in the U.S.A
Cerebrospinal Fluid GABA Levels in Involuntary Movement Disorders N. V. BALA Neurology
MANYAM’
Service, Veterans Administration Neurology Department,
Medical and Regional Office Center, Wilmington, and Thomas Jefferson University, Philadelphia, PA 19107 THEODORE
Department
of Pharmacology,
DE 19805
A. HARE
Thomas Jefferson
(Jniversity, Philadelphia,
PA 19107
AND LEONARD
Neurology
KATZ
Service, Veterans Administration Neurology Department,
Medical and Regional Office Center, Wilmington, and Thomas Jefferson University, Philadelphia, PA 19107
DE 19805
MANYAM, N. V. B., T. A. HARE AND L. KATZ. Cerehrospinalfluid GABA levels in involuntary movement disorders. BRAIN RES. BULL. 5: Suppl. 2, 741-745, 1980.-GABA was measured in cerebrospinal fluid (CSF) from patients with involuntary movement disorders to evaluate the selectivity and specificity of CSF GABA levels in diseases of the basal ganglia and cerebellum. GABA was measured by ion-exchange/fluorometric method from the first 12 ml of CSF. The results showed the mean ( * SD) CSF GABA levels to be 233 2 78 pmoYml in normal controls, 141 + 60 pmol/ml in Hungtinton’s disease, 130 2 48 pmoVm1 in Parkinson’s disease, 125 ? 89 pmoYm1 in Cerebellar degeneration and 125 2 43 pmoYm1 in Essential tremor. Statistical comparison using the Student’s t-test showed that CSF GABA level was significantly reduced in patients with Huntington’s disease, Parkinson’s disease, Cerebellar degeneration and Essential tremor when compared to normal controls. No statistically significant differences were found between Huntington’s disease and other three diseases, showing that low CSF GABA levels are not specific for any one of these diseases. No clear correlation was seen between CSF GABA levels and age, duration, severity of illness, medication or symptoms in either Huntington’s disease or Parkinson’s disease. Involuntary movement disorder Cerebrospinal fluid y-Aminobutyric acid (GABA) Parkinson’s disease Huntington’s disease “At risk” for Huntington’s disease Cerebellar degeneration Essential tremor Sydenham’s chorea Hyperthyroid chorea Psychogenic chorea Tardive dyskinesia Gilles de la Tourette’s syndrome Rigidity Tremor Chorea Bradykinesia Carbidopa Levodopa
INVOLUNTARY movement disorder is a clinical term which generally includes diseases of the extrapyramidal system and the cerebellum. The symptoms seen in this group of diseases include chorea, dystonia, tremor, athetosis, ballismus, myoclonous, ataxia and tics. In the nuclei of the structures associated with the extrapyramidal system-caudate, putamen, globus pallidus, substantia nigra, subthalamic nucleus and cerebellum several neuroactive substances like dopamine, norepinephrine, serotonin, acetylcholine and y-aminobutyric acid (GABA) are present in relatively high concentrations [23]. Biochemical and pharmacological studies in experimental animals.and in man have shown links
between several of the nuerotransmitter systems in the basal ganglia. For example, the main effect of dopamine is inhibitory upon striatal cholinergic intemeurons while acetylcholine mainly exert an excitatory effect on striatal dopaminergic mechanisms. Disturbance of the dopamineacetylcholine balance are thought to result in disorders of voluntary movement. The presence of high concentrations of GABA and its synthesizing enzyme-glutamic acid decarboxylase (GAD) in certain basal ganglia structures, especially the globus pallidus and substrantia nigra, has also been demonstrated [4]. GABA pathways throughout the basal ganglia appear likely to have an impact on the function of the
‘To whom proofs and reprints should be sent: N. V. Bala Manyam, Neurology Service, Veterans Administration OffIce Center, Wilmington, DE 19805.
741
Medical and Regional
MANYAM, HARE AND KATZ
742
striatum, nucleus accumbens and substantia nigra, areas intimately concerned with dopamine action [ 161.A potentially useful approach to evaluate the role of GABA in brain of living patients is the measurement of this inhibitory neurotransmitter in cerebrospinal fluid (CSF) which may reflect alterations of GABA function in the central nervous system. In the initial studies on CSF GABA levels. variations existed among the data from various Iaboratories apart from that due to the analytical procedure. These discrepancies have now been accounted for as a result of studies on the factors that affect stability of GABA under various conditions of collection, storage and sample preparation 161. In the studies reported here, the ion-exchangel~uoromet~c GABA assay procedure 171 was utilized. Neurologicall_y Normal Controls
The control population included 12 males and 8 female adults with a mean (*SD) age of 44 ? 15 years, Five of the 20 were normal volunteers, 2 had serological test for syphilis reactive in blood but non-reactive in CSF. In the remaining patients CSF was obtained as part of neurological evaluation. None of the control group had any organic neurologic or mental disease and were not receiving any drugs. The mean (2 SD) of CSF GABA level in this population was 233 + 78 pmoliml. Comparative studies [S] confirm that CSF GABA levels from individuais without organic or mental disease is identical with CSF GABA levels from normal volunteers. Alterations of GABA level in peripheral organs are unlikely to effect GABA levels in the brain or spinal cord as very little, if any, GABA penetrates through the intact blood brain barrier 110,251. Parkinson’s
TABLE PARKINSON’S
Correlation coefficient CSF GABA* ,, ,I $8 I# /J
vs vs vs vs vs vs
age (in years) duration of illness bradykinesia rigidity tremors dosage of drug?
Significance
0.043
NS NS NS NS NS NS
0.153
0.101 -0.015 0.255 0.393
*pmol/ml. Komparison made in 9 patients taking the amount of Levodopa in Sinemet@. NS=not significant.
TABLE 2 EFFECT OF LEVODOPA
ON CSF GABA LEVELS DISEASE
Untreated Age 35 63 80
%SD
IN PARKINSON’S
Treated
CSF GABA* Age CSF GABA* Carbidopa? 90 103 125
Disease
Parkinson’s Disease manifests with bradykinesia, tremors, rigidity and dementia and pathologically shows diffuse neuronal degeneration with loss of melanin in the substantia nigra. Biochemically, dopamine deficiency has been reported in the basal ganglia and improvement of symptoms results when this deficiency is corrected by the administration of levodopa. CSF GABA was measured in 11 male patients with the mean (*SD) age of 62 ? 12 years. The minimum duration of illness varied from 1 to 10 years. Three of these patients were not receiving any medication at the time of lumbar puncture for CSF collection, 8 were receiving levodopa and the dopa decarboxylase inhibitor-carbidopa (SINEMETe) with a mean dosage of 100 mg of carbidopa and 1000 mg of levodopa. One patient was receiving levodopa alone (6000 mg per day). CSF was colIected following 12 hr of fasting (except water to prevent dehydration), overnight sleep and about 12 hr following the last dose of medication. Neurological expiration was performed just before the lumbar puncture and the Targeting Abnormal Kinetic Effects (TAKE) scale was used for grading Neuroiogical signs. The level of CSF GABA was found to be 130 ? 48 pmoYm1 in these patients and reflected a highly significant difference compared to the controls @ <0.005). No clear correlation between CSF GABA levels and age, duration of illness, bradykinesia, rigidity, tremor or dosage of drug was seen (Table 1). Low levels of CSF GABA in Parkinson’s disease compared to controls has also been reported by others [2,3,111. Our earlier studies 1151 with a small number of patients suggested that levodopa may produce an increase in CSF
1 DISEASE
36 53 57 61 63 63 13 73 63
106 i 18$
138 129 199 192 228 70 92 107 86
75 125 120 7.5 75 100 125 100 0
Levodopat 750 1250 1200 750 750 1000 1250 1000 6000
I38 z+z_56$
*~mo~rn~. tin mg per day administe~d as Sinemet@. SNot significant to each other.
GABA level which would be in keeping with the report that GAD is deficient in certain areas of the brain from untreated patients with Parkinson’s disease, but nearly normal in brains of levodopa treated Parkinson’s disease patients 191. However, the present data indicate that the ability of levodopa to enhance GABA levels in CSF is not consistent or dose related (Table 2). ~M~~ing~on’s Disease
Huntin~on’s disease is an autosomal dominent disease manifested by chorea, dementia and rigidity. Atrophy of the caudate nucleus, loss of small neurons in caudate nucleus and putamen associated with astrocytic infdtration forms the main pathological picture. The clinical interest in GABA measurements developed when decreased levels of this putative inhibitory neurotransmitter was demonstrated in the basal ganglia of autopsied brain tissue of patients who had died with Huntington’s disease when compared to controls [ 1, 19, 241. This interest was further augmented when decreased level of GABA was found in the CSF of patients with
CSF GABA IN MOVEMENT
743
DISORDERS TABLE 3 CSF GABA LEVELS IN HUNTINGTON’S DISEASE EFFECT OF DRUGS Medication group (n=ll)
Medication free group (n= 12)
Medication
Age
Sex
CSF GABA*
Age
Sex
1.
19
F
176
38
M
133
Haloperidol
2.
26
M
129
39
F
107
Amitryiptyline hydrochloride
3.
27
M
116
40
M
117
Chlorpromazine hydrochloride
4.
30
M
120
44
F
93
5.
30
M
91
48
M
107
Haloperidol + impramine hydrochloride
6.
43
M
176
52
F
121
Chlorpromazine hydrochloride
7.
44
M
136
53
F
66
8.
48
M
294
56
F
132
Diazepam
9.
53
M
121
57
M
115
Diazepam & fluphenazine
57
M
256
Perphenazine
59
F
115
Haloperidol & dean01 acetamidobenzoate
49 k 8
516
10.
59
M
304
11.
62
M
119
12.
65
M
%SD
42 t 16
11/l
CSF GABA*
Diazepam
Haloperidol
113 158 +
701
124 2
481
*pmoYml. tNot significant to each other.
TABLE 4 Huntington’s disease [3, 5, 13, 141 and in about 60% of individuals “at risk” for Huntington’s disease [ 131. CSF GABA from 23 patients (16 males and 7 females) with known Huntington’s disease were evaluated. The mean (*SD) age was 46 ? 12 years. The minimum duration of illness ranged from 1 to 20 years and the degree of chorea ranged from 1 to 4 based on the Abnormal Involuntary Movement Scale (AIMS). Twelve of the patients were not receiving any medication at the time of lumbar puncture and the remaining 11 were on various drugs as listed in Table 3. The mean (+-SD) CSF GABA level in these patients was found to be 141 + 60 pmoYm1 (mean 2 SD), which reflects a significantly reduced level as compared to the controls (p
Essential tremor is a monosymptomatic disorder characterized by postural and action tremors which is usually precipitated by anxiety. Both autosomal dominant and sporadic forms are reported, but no specific pathological or biochemical changes in the brain has yet been demonstrated. Five male patients with the mean age of 58 ? 6 years had a mean (? SD) CSF GABA level of 12.5 * 43 pmoVm1
HUNTINGTON’S DISEASE Correlation coefficient
Significance
-0.149 -0.120 -0.131
NS NS NS
CSF GABA*vs age (in years) I, vs duration of illness vs severity of chorea 0 pmol/ml .
TABLE 5 CSF GABA LEVEL IN ESSENTIAL TREMOR Age in years
CSF GABA pmoYm1
1 2 3 4
51 58 62 66
99 186 73 133
5
54
135
58 2 6
125 _f 43
Patient
: k SD
Drug & dosage
None None None Amantadine HCl 200 mgiday Diazepam 20 mg/day
744
MANYAM,
HARE AND KATZ
TABLE 6 CSF GABA Patient
LEVEL IN CEREBELLAR
Etiology
1
Age in years
CSF GABA pmoliml
u I,
46 69 48 59 59 60
36 I95 152 2.53 77 37
x 2 SD
57 I 8
125 t 89
Alcoholic ,‘
2 3 4 5 6
DEGENERATION
Idiopathic
I,
*
PC. 0 005
** P-zO.05
+
T
*+
T
TABLE 7 CSF GABA LEVELS IN MISCELLANEOUS MOVEMENT DISORDERS
INVOLUNTARY
Age in years
Sex
CSF GABA pmoiiml
Chorea - Sydenham’s Chorea - birth injury Chorea - hy~~hyroid
8 24 27
M M M
202 22% 207
Chorea - psychogenic with dementia
69
M
78
Cilles de la Tourette’s Syndrome
44
M
110
Tardive dyskinesia
70
M
39
Diagnosis
FIG. 1. CSF CABA levels in involuntary movement disorders.
(Table 5). This value is significantly controls @
lower than that of the
Cerebeliar Degeneration Cerebellar degeneration can be hereditary or could result from numerous toxic reactions (example-alcohol and diphenylhydantoin~, non”me~~tic m~es~tion of neoplasm and in some cases no obvious cause can be found. The cerebellum is reported to contain a relatively high level of GABA when compared to the amount reported in certain cerebellar degenerative disease [20]. The participants in our study included 2 males with cerebellar ataxia associated with chronic alcohol intake and 4 males in whom no cause could be found (idiopathic). The mean age of these patients was 57 rt 8 years and the mean (*SD} CSF GABA level was 125 ” 89 pmoUml (Table 6) reflecting a significantly reduced level as compared to the controls (p
ln~o~unta~ Movement Disorders
Chorea as a symptom is known to occur in several disorders in addition to Huntington’s disease. CSF GABA level ranged from low to normal in one each of patients with Sydenham’s chorea, chorea due to birth injury, hyperthyroidism with chorea, Psychogenic chorea with dementia, Gibes de la Tourette’s Syndrome and Tardive dyskinesia (Table 7). However, no definite conclusion can be drawn
until a large number of samples from patients with the above diseases are examined. CONCLUSION
The findings of low levels of GABA in the brain [ 1, 19,241 and CSF [3, 5, 13, 141 of patients with Huntington’s disease stimtdated the effort to evaluate GABA levels in other neurologic diseases especially where involunt~ movements were present. Low CSF GABA levels in Huntington’s disease appear to be a reflection of a decreased level of GABA and GAD in the brain of patients who died of this disease [ 1,17,22]. Similar supportive data has been reported for Parkinson’s disease since decreased levels of GAD activity has been observed in the basal ganglia of individuals dying with this disease [ 12, 18,211. Such a verification is not available for other diseases. The results presented here demonstrate that reduced CSF GABA levels are not specific for any of these disorders (Fig. 1). Both in Huntington’s disease and Parkinson’s disease, there is a lack of correlation between CSF GABA levels and the duration or severity of the disease or the effect of medication. This suggests that decreased levels of CSF GABA may not be the result of neuronai degeneration, but rather an alteration of GABA metabolism.
CSF GABA IN MOVEMENT
DISORDERS
745
A~KNOWLE~EMENTS
This work was supported in part by the Genera1 Medical Research Program of the Veterans Administration, Hereditary Disease
Foundation and the National Institute of Mental Health (MH 28343). Robert D. Trembley, B.S., and Kathryn Kiniefski provided technicaf assistance, Catharine B&anger provided secretarial help and Phyllis, W. Hines, R.N., and her staff provided nursing assistance.
REFERENCES Bird, E. D., A. V. P. MacKay, C. N. Rayner and L. L. Iverson. Reduced glutamic acid decarboxylase activity of postmortem brain in Huntington’s chorea. Lancer I: 1090-1092, 1973. 2. Chase, N. T. and C. A. Tamminga. GABA system participation in human motor, cognitive and endocrine function. In: GABA Neuratransmitters, edited by P. Krogsgaard-Larson, J. &heel-Kluaer and H. Koford. New York: Academic Press, 1979, pp. 284-294. 3. Enna, S. J., L. Z. Stem, G. J. Wastek and H. I. Yamamura. Cerebrospinal fluid y-aminobutyric acid variations in neurological disorders. Archs Neurol. 34: 683-685. 1977. 4. Fahn, S. Regional distribution studies of GABA and other putative neurotransmitters and their enzymes. In: GABA in Nervous Svstem Function. edited bv E. Roberts. T. N. Chase and D. Et. Tower. New York: Raven-Press, 1976,‘~~. 169-186. 5. Glaeser, B. S., W. H. Vogel, D. B. Oleweiler and T. A. Hare. GABA levels in cerebrospinaI fluid of patients with Huntington’s chorea. B&hem. Med. 12: 380-385. 1975. 6. Grossman, M. H., T. A. Hare, N. V. B. Manyam, B. S. Glaeser and J. H. Wood. Stability of GABA in CSF under various conditions of storage. Brain Res. 182: 99-106. 1980. 7. Hare, T. A. and N. V. B. Manyam. Rapid and sensitive ionexchan~e~fluoromet~c measurement of GABA in physiological fluids. An&t. Bin&em. 101: 349-355, 1980. 8. Hare. T. A.: J. H. Wood. N. V. B. Manvam, J. C. Ballenaer, R. M. Post and R. H. Gem&. Selection ofcontrol populations for clinical cerebrospinal fluid GABA investigations based on comparison with normal volunteers. Brain Res. Bull. 5: Suppl. 2, 721-724, 1980. 9. Homykiewicz, O., K. G. Lloyd and L. Davidson. The GABA system and function of the basal ganglia and Parkinson’s disease. In: GABA in Nervous System, edited by E. Roberts, T. N. Chase and D. B. Towers. New York: Raven Press, 1976, pp. 479-485. 10. Kuriyama, K. and P. Y. Sze. Amino-oxyacetic acid and the blood brain barrier to gamma-aminobutyric acid. Pharmacologisr 12: 207, 1970. 11. Laake. J. P. N. F. and A. W. Teelken. Amino acid abnormalities in cerebrospinal fluid of patients with Parkinsonism and extrapyramidaI disorders. Neurology 5: 489-493, 1976. 12. Lloyd, K. G., L. Davidson and 0. Hornykiewicz. Metabolism of levodopa in the human brain. In: Adv. Neural., Vol. 3, Progress in the Treatment of Parkinson’s Disease, edited by D. B. Calne. New York: Raven Press, 1973, pp. 173-188. 13. Manyam, N. V. B., T. A. Hare, L. Katz and B. S. Glaeser. Huntington’s disease. Cerebrospinal fluid GABA levels in at risk individu~s. Archs Neurof. 34: 728-730, 1978.
14. Many~, N. V. B., T. A. Hare and L. Katz. Cerebrospinal fluid GABA levels in Huntington’s Disease, at “risk for” Huntington’s Disease and normal controls. In: Adv. Neural., Vol. 23, Huminaton’s Disease. edited bv T. N. Chase. N. S. Wexler and A. B&beau. New York: Raven Press, 1979: pp. 547-556. 15. Manyam, N. V. B., L. Katz, T. A. Hare, J. C. Gerber III and M. H. Grossman. Levels of raminobutyric acid in cerebrospinal fluid in various neurologic disorders. Archs Neural., in press. diseases, 16. Marsden, C. D. GABA in relation to extrapy~mid~ with particular relevance to animal models. In: GABANeur&ansmitters, edited by P. Krogsgaard-Larsen, J. Scheel-Krtieer and H. Koford. New York: Academic Press, 1979, pp. 295-307. 17. McGeer, R. L., E. G. McGeer and H. C. Fibiger. Choline acetyiase and glutamic acid decarboxylase in Huntington’s chorea. Neurology, Minaeap. 2% 912-917, 1973. 18. McGeer, P. L. and E. G. McGeer. Enzymes associated with the metabolism of catecholamines, acetylcholine and GABA in human controls and patients with Parkinson’s Disease and Huntington’s Chorea. J. Neurochem. 26: 65-76, 1976. 19. Perry, T. L., S. Hansen and M. Kloster. Huntington’s chorea: Deficiency of gamma-aminobutyric acid in brain. NewI En&. J. Med. 288: 337-342, 1973. 20. Perry, T. L., S. Hansen, R, D. Currier and K. Berry. Abnormalities in neurotransmitter amino acids in dominantly inherited cerebellar disorders. In: Advances in Neurology, Voi. 21. The Inherited Afaxias, edited by R. A. P. Kark, R. N. Rosenberg and L. J. Schut. New York: Raven Press, 1978, pp. 303314. 21. Rinne, U. K., H. Laaksonen, P. Riekkinen and V. Sonninen. Brain glutamic acid decarboxylase activity in Parkinson’s Disease. Eur. Neur~~l. 12: 13-19, 1974. 22. Stahl, W. L. and P. D. Swanson. Biochemical abnormalities in Huntington’s chorea brains. Neurology 24: 813-819, 1974. 23. Tolosa, E. S. Parkinson’s disease, Huntington’s disease and tardive dyskinesia-neurochemical pathology and treatment. Minn. Med. 62: 101-106, 1979. 24. Urquhart, N., T. L. Perry, S. Hansen and J. Kennedy. GABA content and glutamic acid decarboxylase activity in brain of Huntington’s chorea patients and control subjects. .I. Neurachem.
24: 1071-1075,
1975.
25. Van Gelder, N. M. and K. A. C. Elliott. Disposition of y-aminobutyric acid administration to mammals. J. Neurochem. 3: 139-143,
1958.
Vol. 5,
Suppl.2, pp.741-745.
Printed
in the U.S.A
Cerebrospinal Fluid GABA Levels in Involuntary Movement Disorders N. V. BALA Neurology
MANYAM’
Service, Veterans Administration Neurology Department,
Medical and Regional Office Center, Wilmington, and Thomas Jefferson University, Philadelphia, PA 19107 THEODORE
Department
of Pharmacology,
DE 19805
A. HARE
Thomas Jefferson
(Jniversity, Philadelphia,
PA 19107
AND LEONARD
Neurology
KATZ
Service, Veterans Administration Neurology Department,
Medical and Regional Office Center, Wilmington, and Thomas Jefferson University, Philadelphia, PA 19107
DE 19805
MANYAM, N. V. B., T. A. HARE AND L. KATZ. Cerehrospinalfluid GABA levels in involuntary movement disorders. BRAIN RES. BULL. 5: Suppl. 2, 741-745, 1980.-GABA was measured in cerebrospinal fluid (CSF) from patients with involuntary movement disorders to evaluate the selectivity and specificity of CSF GABA levels in diseases of the basal ganglia and cerebellum. GABA was measured by ion-exchange/fluorometric method from the first 12 ml of CSF. The results showed the mean ( * SD) CSF GABA levels to be 233 2 78 pmoYml in normal controls, 141 + 60 pmol/ml in Hungtinton’s disease, 130 2 48 pmoVm1 in Parkinson’s disease, 125 ? 89 pmoYm1 in Cerebellar degeneration and 125 2 43 pmoYm1 in Essential tremor. Statistical comparison using the Student’s t-test showed that CSF GABA level was significantly reduced in patients with Huntington’s disease, Parkinson’s disease, Cerebellar degeneration and Essential tremor when compared to normal controls. No statistically significant differences were found between Huntington’s disease and other three diseases, showing that low CSF GABA levels are not specific for any one of these diseases. No clear correlation was seen between CSF GABA levels and age, duration, severity of illness, medication or symptoms in either Huntington’s disease or Parkinson’s disease. Involuntary movement disorder Cerebrospinal fluid y-Aminobutyric acid (GABA) Parkinson’s disease Huntington’s disease “At risk” for Huntington’s disease Cerebellar degeneration Essential tremor Sydenham’s chorea Hyperthyroid chorea Psychogenic chorea Tardive dyskinesia Gilles de la Tourette’s syndrome Rigidity Tremor Chorea Bradykinesia Carbidopa Levodopa
INVOLUNTARY movement disorder is a clinical term which generally includes diseases of the extrapyramidal system and the cerebellum. The symptoms seen in this group of diseases include chorea, dystonia, tremor, athetosis, ballismus, myoclonous, ataxia and tics. In the nuclei of the structures associated with the extrapyramidal system-caudate, putamen, globus pallidus, substantia nigra, subthalamic nucleus and cerebellum several neuroactive substances like dopamine, norepinephrine, serotonin, acetylcholine and y-aminobutyric acid (GABA) are present in relatively high concentrations [23]. Biochemical and pharmacological studies in experimental animals.and in man have shown links
between several of the nuerotransmitter systems in the basal ganglia. For example, the main effect of dopamine is inhibitory upon striatal cholinergic intemeurons while acetylcholine mainly exert an excitatory effect on striatal dopaminergic mechanisms. Disturbance of the dopamineacetylcholine balance are thought to result in disorders of voluntary movement. The presence of high concentrations of GABA and its synthesizing enzyme-glutamic acid decarboxylase (GAD) in certain basal ganglia structures, especially the globus pallidus and substrantia nigra, has also been demonstrated [4]. GABA pathways throughout the basal ganglia appear likely to have an impact on the function of the
‘To whom proofs and reprints should be sent: N. V. Bala Manyam, Neurology Service, Veterans Administration OffIce Center, Wilmington, DE 19805.
741
Medical and Regional
MANYAM, HARE AND KATZ
742
striatum, nucleus accumbens and substantia nigra, areas intimately concerned with dopamine action [ 161.A potentially useful approach to evaluate the role of GABA in brain of living patients is the measurement of this inhibitory neurotransmitter in cerebrospinal fluid (CSF) which may reflect alterations of GABA function in the central nervous system. In the initial studies on CSF GABA levels. variations existed among the data from various Iaboratories apart from that due to the analytical procedure. These discrepancies have now been accounted for as a result of studies on the factors that affect stability of GABA under various conditions of collection, storage and sample preparation 161. In the studies reported here, the ion-exchangel~uoromet~c GABA assay procedure 171 was utilized. Neurologicall_y Normal Controls
The control population included 12 males and 8 female adults with a mean (*SD) age of 44 ? 15 years, Five of the 20 were normal volunteers, 2 had serological test for syphilis reactive in blood but non-reactive in CSF. In the remaining patients CSF was obtained as part of neurological evaluation. None of the control group had any organic neurologic or mental disease and were not receiving any drugs. The mean (2 SD) of CSF GABA level in this population was 233 + 78 pmoliml. Comparative studies [S] confirm that CSF GABA levels from individuais without organic or mental disease is identical with CSF GABA levels from normal volunteers. Alterations of GABA level in peripheral organs are unlikely to effect GABA levels in the brain or spinal cord as very little, if any, GABA penetrates through the intact blood brain barrier 110,251. Parkinson’s
TABLE PARKINSON’S
Correlation coefficient CSF GABA* ,, ,I $8 I# /J
vs vs vs vs vs vs
age (in years) duration of illness bradykinesia rigidity tremors dosage of drug?
Significance
0.043
NS NS NS NS NS NS
0.153
0.101 -0.015 0.255 0.393
*pmol/ml. Komparison made in 9 patients taking the amount of Levodopa in Sinemet@. NS=not significant.
TABLE 2 EFFECT OF LEVODOPA
ON CSF GABA LEVELS DISEASE
Untreated Age 35 63 80
%SD
IN PARKINSON’S
Treated
CSF GABA* Age CSF GABA* Carbidopa? 90 103 125
Disease
Parkinson’s Disease manifests with bradykinesia, tremors, rigidity and dementia and pathologically shows diffuse neuronal degeneration with loss of melanin in the substantia nigra. Biochemically, dopamine deficiency has been reported in the basal ganglia and improvement of symptoms results when this deficiency is corrected by the administration of levodopa. CSF GABA was measured in 11 male patients with the mean (*SD) age of 62 ? 12 years. The minimum duration of illness varied from 1 to 10 years. Three of these patients were not receiving any medication at the time of lumbar puncture for CSF collection, 8 were receiving levodopa and the dopa decarboxylase inhibitor-carbidopa (SINEMETe) with a mean dosage of 100 mg of carbidopa and 1000 mg of levodopa. One patient was receiving levodopa alone (6000 mg per day). CSF was colIected following 12 hr of fasting (except water to prevent dehydration), overnight sleep and about 12 hr following the last dose of medication. Neurological expiration was performed just before the lumbar puncture and the Targeting Abnormal Kinetic Effects (TAKE) scale was used for grading Neuroiogical signs. The level of CSF GABA was found to be 130 ? 48 pmoYm1 in these patients and reflected a highly significant difference compared to the controls @ <0.005). No clear correlation between CSF GABA levels and age, duration of illness, bradykinesia, rigidity, tremor or dosage of drug was seen (Table 1). Low levels of CSF GABA in Parkinson’s disease compared to controls has also been reported by others [2,3,111. Our earlier studies 1151 with a small number of patients suggested that levodopa may produce an increase in CSF
1 DISEASE
36 53 57 61 63 63 13 73 63
106 i 18$
138 129 199 192 228 70 92 107 86
75 125 120 7.5 75 100 125 100 0
Levodopat 750 1250 1200 750 750 1000 1250 1000 6000
I38 z+z_56$
*~mo~rn~. tin mg per day administe~d as Sinemet@. SNot significant to each other.
GABA level which would be in keeping with the report that GAD is deficient in certain areas of the brain from untreated patients with Parkinson’s disease, but nearly normal in brains of levodopa treated Parkinson’s disease patients 191. However, the present data indicate that the ability of levodopa to enhance GABA levels in CSF is not consistent or dose related (Table 2). ~M~~ing~on’s Disease
Huntin~on’s disease is an autosomal dominent disease manifested by chorea, dementia and rigidity. Atrophy of the caudate nucleus, loss of small neurons in caudate nucleus and putamen associated with astrocytic infdtration forms the main pathological picture. The clinical interest in GABA measurements developed when decreased levels of this putative inhibitory neurotransmitter was demonstrated in the basal ganglia of autopsied brain tissue of patients who had died with Huntington’s disease when compared to controls [ 1, 19, 241. This interest was further augmented when decreased level of GABA was found in the CSF of patients with
CSF GABA IN MOVEMENT
743
DISORDERS TABLE 3 CSF GABA LEVELS IN HUNTINGTON’S DISEASE EFFECT OF DRUGS Medication group (n=ll)
Medication free group (n= 12)
Medication
Age
Sex
CSF GABA*
Age
Sex
1.
19
F
176
38
M
133
Haloperidol
2.
26
M
129
39
F
107
Amitryiptyline hydrochloride
3.
27
M
116
40
M
117
Chlorpromazine hydrochloride
4.
30
M
120
44
F
93
5.
30
M
91
48
M
107
Haloperidol + impramine hydrochloride
6.
43
M
176
52
F
121
Chlorpromazine hydrochloride
7.
44
M
136
53
F
66
8.
48
M
294
56
F
132
Diazepam
9.
53
M
121
57
M
115
Diazepam & fluphenazine
57
M
256
Perphenazine
59
F
115
Haloperidol & dean01 acetamidobenzoate
49 k 8
516
10.
59
M
304
11.
62
M
119
12.
65
M
%SD
42 t 16
11/l
CSF GABA*
Diazepam
Haloperidol
113 158 +
701
124 2
481
*pmoYml. tNot significant to each other.
TABLE 4 Huntington’s disease [3, 5, 13, 141 and in about 60% of individuals “at risk” for Huntington’s disease [ 131. CSF GABA from 23 patients (16 males and 7 females) with known Huntington’s disease were evaluated. The mean (*SD) age was 46 ? 12 years. The minimum duration of illness ranged from 1 to 20 years and the degree of chorea ranged from 1 to 4 based on the Abnormal Involuntary Movement Scale (AIMS). Twelve of the patients were not receiving any medication at the time of lumbar puncture and the remaining 11 were on various drugs as listed in Table 3. The mean (+-SD) CSF GABA level in these patients was found to be 141 + 60 pmoYm1 (mean 2 SD), which reflects a significantly reduced level as compared to the controls (p
Essential tremor is a monosymptomatic disorder characterized by postural and action tremors which is usually precipitated by anxiety. Both autosomal dominant and sporadic forms are reported, but no specific pathological or biochemical changes in the brain has yet been demonstrated. Five male patients with the mean age of 58 ? 6 years had a mean (? SD) CSF GABA level of 12.5 * 43 pmoVm1
HUNTINGTON’S DISEASE Correlation coefficient
Significance
-0.149 -0.120 -0.131
NS NS NS
CSF GABA*vs age (in years) I, vs duration of illness vs severity of chorea 0 pmol/ml .
TABLE 5 CSF GABA LEVEL IN ESSENTIAL TREMOR Age in years
CSF GABA pmoYm1
1 2 3 4
51 58 62 66
99 186 73 133
5
54
135
58 2 6
125 _f 43
Patient
: k SD
Drug & dosage
None None None Amantadine HCl 200 mgiday Diazepam 20 mg/day
744
MANYAM,
HARE AND KATZ
TABLE 6 CSF GABA Patient
LEVEL IN CEREBELLAR
Etiology
1
Age in years
CSF GABA pmoliml
u I,
46 69 48 59 59 60
36 I95 152 2.53 77 37
x 2 SD
57 I 8
125 t 89
Alcoholic ,‘
2 3 4 5 6
DEGENERATION
Idiopathic
I,
*
PC. 0 005
** P-zO.05
+
T
*+
T
TABLE 7 CSF GABA LEVELS IN MISCELLANEOUS MOVEMENT DISORDERS
INVOLUNTARY
Age in years
Sex
CSF GABA pmoiiml
Chorea - Sydenham’s Chorea - birth injury Chorea - hy~~hyroid
8 24 27
M M M
202 22% 207
Chorea - psychogenic with dementia
69
M
78
Cilles de la Tourette’s Syndrome
44
M
110
Tardive dyskinesia
70
M
39
Diagnosis
FIG. 1. CSF CABA levels in involuntary movement disorders.
(Table 5). This value is significantly controls @
lower than that of the
Cerebeliar Degeneration Cerebellar degeneration can be hereditary or could result from numerous toxic reactions (example-alcohol and diphenylhydantoin~, non”me~~tic m~es~tion of neoplasm and in some cases no obvious cause can be found. The cerebellum is reported to contain a relatively high level of GABA when compared to the amount reported in certain cerebellar degenerative disease [20]. The participants in our study included 2 males with cerebellar ataxia associated with chronic alcohol intake and 4 males in whom no cause could be found (idiopathic). The mean age of these patients was 57 rt 8 years and the mean (*SD} CSF GABA level was 125 ” 89 pmoUml (Table 6) reflecting a significantly reduced level as compared to the controls (p
ln~o~unta~ Movement Disorders
Chorea as a symptom is known to occur in several disorders in addition to Huntington’s disease. CSF GABA level ranged from low to normal in one each of patients with Sydenham’s chorea, chorea due to birth injury, hyperthyroidism with chorea, Psychogenic chorea with dementia, Gibes de la Tourette’s Syndrome and Tardive dyskinesia (Table 7). However, no definite conclusion can be drawn
until a large number of samples from patients with the above diseases are examined. CONCLUSION
The findings of low levels of GABA in the brain [ 1, 19,241 and CSF [3, 5, 13, 141 of patients with Huntington’s disease stimtdated the effort to evaluate GABA levels in other neurologic diseases especially where involunt~ movements were present. Low CSF GABA levels in Huntington’s disease appear to be a reflection of a decreased level of GABA and GAD in the brain of patients who died of this disease [ 1,17,22]. Similar supportive data has been reported for Parkinson’s disease since decreased levels of GAD activity has been observed in the basal ganglia of individuals dying with this disease [ 12, 18,211. Such a verification is not available for other diseases. The results presented here demonstrate that reduced CSF GABA levels are not specific for any of these disorders (Fig. 1). Both in Huntington’s disease and Parkinson’s disease, there is a lack of correlation between CSF GABA levels and the duration or severity of the disease or the effect of medication. This suggests that decreased levels of CSF GABA may not be the result of neuronai degeneration, but rather an alteration of GABA metabolism.
CSF GABA IN MOVEMENT
DISORDERS
745
A~KNOWLE~EMENTS
This work was supported in part by the Genera1 Medical Research Program of the Veterans Administration, Hereditary Disease
Foundation and the National Institute of Mental Health (MH 28343). Robert D. Trembley, B.S., and Kathryn Kiniefski provided technicaf assistance, Catharine B&anger provided secretarial help and Phyllis, W. Hines, R.N., and her staff provided nursing assistance.
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