Increased concentrations of aspartic acid in the cerebrospinal fluid of patients with epilepsy and trigeminal neuralgia: an effect of medication?

Narrow ovale foramina may be involved in the development of primary trigeminal neuralgia

Background

The etiology of primary trigeminal neuralgia remains unclear and is worthy of further study; In this study, the morphometric characteristics of ovale foramina between various groups were compared and analyzed to explore the novel cause of primary trigeminal neuralgia.

Methods

High-resolution three-dimensional reconstruction images from head computed tomography of 109 patients with primary trigeminal neuralgia affecting the third branch of the trigeminal nerve and 46 healthy controls were retrospectively reviewed. Among the 109 primary trigeminal neuralgia patients, 79 patients with apparent neurovascular compression (not simply contact) demonstrated on MRI or during surgery were divided into the classical trigeminal neuralgia group and 30 patients with MRI showing no significant abnormalities were divided into idiopathic trigeminal neuralgia group. The morphometric parameters including the area, width and length of ovale foramina were examined through the use of radiologic methods.

Results

In this study, the average minimum area, width and length of 79 ovale foramina on the affected and unaffected sides in the classical trigeminal neuralgia group were 21.83 ± 8.45, 21.94 ± 7.93 mm², 2.32 ± 0.91, 2.58 ± 0.81, 5.32 ± 1.29, and 5.26 ± 1.21 mm, respectively. No significant difference in these parameters was observed (p > 0.05). However, in the idiopathic trigeminal neuralgia group, the average minimum area, width and length of 30 ovale foramina were 21.33 ± 8.21, 22.85 ± 8.36 mm², 2.25 ± 0.90, 2.79 ± 0.96, 5.20 ± 1.27, and 5.28 ± 1.19 mm, respectively. The width on the symptomatic side was significantly smaller (p = 0.03) than that on the asymptomatic side. No significant difference in area (p = 0.48) or length (p = 0.79) was observed. In addition, when compared with the healthy control group, the area and width of ovale foramina on the symptomatic side in both groups were significantly smaller. No significant difference in length was observed.

Conclusions

By comparing and analyzing the statistical data, it can be inferred that a narrow foramen ovale is associated with primary trigeminal neuralgia, as well as its recurrence after microvascular decompression.

A study of glutamate excitotoxicity in seizures related to tuberculous meningitis

BACKGROUND AND PURPOSE

Glutamate is a neurotransmitter that regulates approximately half of the nervous system, along with the sensory system. Glutamate excitotoxicity is related to seizures but its role in TBM-related seizure has not been reported to our best knowledge. It is proposed to report plasma glutamate level and its receptors in TBM patients with seizures and correlate with the type of seizures, Magnetic Resonance Imaging (MRI) findings, and outcome.

METHODS

TBM was diagnosed clinically with MRI as well as cerebrospinal fluid examination. TBM-related seizures have been categorized into early (< 1 month) or late (> 1 month) seizures. Six months outcome was defined using modified Rankin Scale as good (mRS ≤ 2) or poor (mRS > 2). Plasma glutamate was measured by ELISA, along with NR1, NR2A, and NR2B receptors using Real Time Polymerase Chain Reaction (RT-PCR) and have been correlated with seizure, MRI abnormalities, and outcome.

RESULTS

A total of 29 (53.7%) patients developed seizures (early-09, late-20). Glutamate (P < 0.0001), NR1 (p ≤ 0.0001), NR2A (p ≤ 0.0001), and NR2B (p ≤ 0.0001) were higher than the controls. In TBM patients with seizures, plasma glutamate (p = 0.01), NR1 (p = 0.03) and NR2A (p = 0.001) were significantly higher than those without seizures. Plasma glutamate level and all three receptor genes expression were higher during seizures and improved on cessation of seizure compared to the baseline. These markers correlated well with MRI findings and determined the outcome. ROC curve was used to estimate the diagnostic accuracy of the markers. The result indicated that NR2A gene was the best predictor followed by glutamate and NR1 gene.

CONCLUSION

Our results highlight the role of glutamate and its receptors in TBM-related seizures and outcomes.

Increased CSF Levels of Apolipoproteins and Complement Factors in Trigeminal Neuralgia Patients-In Depth Proteomic Analysis Using Mass Spectrometry

The main cause of trigeminal neuralgia (TN) is compression of a blood vessel at the root entry zone of the trigeminal nerve. However, a neurovascular conflict does not seem to be the only etiology and other mechanisms are implicated in the development of the disease. We hypothesized that TN patients may have distinct protein expression in the CSF. In this study, lumbar CSF from TN patients (n = 17), scheduled to undergo microvascular decompression, and from controls (n = 20) was analyzed and compared with in depth mass spectrometry TMTbased quantitative proteomics. We identified 2552 unique proteins, of which 46 were significantly altered (26 increased, and 20 decreased, q-value < .05) in TN patients compared with controls. An over-representation analysis showed proteins involved in high-density lipoprotein, such as Apolipoprotein A4, Apolipoprotein M, and Apolipoprotein A1, and the extracellular region, including proteins involved in the complement cascade to be over-represented. We conclude that TN patients have distinct protein expression in the CSF compared to controls. The pathophysiological background of the protein alterations found in this study warrants further investigation in future studies. PERSPECTIVE: In this article, cerebrospinal fluid from patients with trigeminal neuralgia was analyzed using in depth shotgun proteomics, revealing 46 differentially expressed proteins compared to controls. Among these, apolipoproteins and proteins involved in the complement system were elevated and significantly over-represented, implying an inflammatory component in the pathophysiology of the disease.

Plasma and cerebrospinal fluid amino acids in epileptic patients

Altered plasma and cerebrospinal fluid amino acid levels may be associated with human epilepsy. We studied three groups of patients, those with a generalized epileptic syndrome, juvenile myoclonic epilepsy, patients with refractory localization-related epilepsies, and patients with acute seizures (within 24 h). Plasma levels of amino acids were studied in all patient groups, as were those in the cerebrospinal fluid (CSF) of patients with acute seizures. After acute seizures, the amino acid changes in the CSF were limited to a reduction in the level of taurine, whereas the levels of most amino acids in plasma were decreased. On the other hand, levels of the excitatory amino acids glutamate and aspartate were increased. The most notable finding in the juvenile myoclonic epilepsy patients was an increase in glutamate level in the plasma. Our study supports the conception of an altered metabolism of glutamate in generalized epilepsies.

Amino acid composition of brain cysts: levels of excitatory amino acids in cyst fluid fail to predict seizures

A recent study describing two epileptic patients with brain cysts has suggested that elevated concentrations of excitatory amino acids in cysts may play a role in induction and maintenance of epileptogenesis [Epilepsy Res. 28 (1997) 245]. Here, we report that only in 3 out of 22 patients with brain cysts undergoing brain surgery cyst fluids displayed highly increased amounts of the excitatory amino acids aspartate and/or glutamate. Two of these patients experienced epileptic seizures prior to neurosurgical intervention. Thus, highly increased excitatory amino acid levels are present only in a subset of patients with brain cysts. Our observation that one patient with highly increased glutamate and aspartate concentrations in the cyst did not display seizures or typical epileptiform potentials in the EEG questions that these excitatory amino acids in the cyst fluid are directly involved in epileptogenicity. This patient displayed an increased level of adenosine in the cyst fluid, which is known to have anticonvulsant properties and might provide protection from seizures. In summary, there is no evidence for a close correlation between excitatory amino acids in brain cysts and the occurrence of seizures.

Plasma amino acids in childhood epileptic encephalopathies

Abnormalities in plasma amino acid levels have been noted in patients with various epilepsies, and sometimes also in their first degree relatives. We sought to study plasma amino acid levels in children with epileptic encephalopathies and their parents, relating findings to the pattern of cortical glucose metabolism as determined by 18fluorodeoxyglucose (FDG) positron emission tomography (PET). Twenty-eight children with cryptogenic epileptic encephalopathies were studied prospectively. Cortical glucose metabolism was evaluated by FDG PET with combined visual and semiquantitative analysis used to detect focal cortical defects. The plasma concentration of 21 amino acids in the children and their parents was measured by ion exchange chromatography and compared with control values using non-parametric statistical methods. Multivariate analysis was used to assess antiepileptic drug effects. Children were classified as: Lennox-Gastaut syndrome following infantile spasms (six patients); de-novo Lennox-Gastaut syndrome (eight); severe myoclonic epilepsy in infancy (eight) and myoclonic-astatic epilepsy (two). Four patients remained unclassified. Fourteen patients had focal/multifocal abnormalities on PET scans. The plasma level of aspartate was significantly lower in both the children with epileptic encephalopathies and in their parents (P < 0.005). The lowered aspartate levels could not be accounted for by the antiepileptic drug medication taken by the children. Further analysis showed the lowered aspartate levels to be confined to children and their parents who lacked focal PET abnormalities. These findings suggest a possible genetic abnormality in the aspartate neurotransmitter systems in the pathogenesis of seizures in the childhood epileptic encephalopathies.

Effect of sustained pyridoxine treatment on seizure susceptibility and regional brain amino acid levels in genetically epilepsy-prone BALB/c mice

Epilepsy-prone and epilepsy-resistant substrains were selectively bred from a strain of BALB/c mice; audiogenic-sensitive epilepsy-prone animals showed enhanced sensitivity to chemical convulsants. Treatment with pyridoxine (100 mg/L in drinking water) initiated at mating and continued throughout pregnancy and the life of the offspring abolished the enhanced sensitivity to chemical convulsants and reduced the severity of audiogenic seizures. Withdrawal of pyridoxine restored the enhanced seizure sensitivity. [1H] Nuclear magnetic resonance (NMR) spectroscopy of perchloric acid extracts of tissue was used to determine the concentrations of several compounds [N-acetylaspartate (NAA), GABA, glutamate, aspartate, alanine, taurine, creatine, cholines, inositol] in the hippocampus, neocortex, brainstem, and cerebellum of untreated and pyridoxine-treated 6-week-old female animals. The ratios of the concentrations of excitatory to inhibitory putative neurotransmitter amino acids tended to be higher in epilepsy-prone animals, with the most pronounced difference being a significantly elevated glutamate/GABA ratio in every brain region examined. Pyridoxine treatment abolished this imbalance in the hippocampus, brainstem, and cerebellum, but not in the neocortex. Treatment of epilepsy-resistant animals with pyridoxine using the same protocol decreased the glutamate/GABA concentration ratio in the hippocampus, brainstem, and neocortex and resulted in impaired development of the animals. The amino acid imbalance and the accompanying seizure susceptibility in these genetically epilepsy prone mice may originate from an inborn error in pyridoxine metabolism or in a pyridoxine-dependent enzyme system.

Regional excitatory and inhibitory amino acid levels in epileptic El mouse brain

Inbred mutant El mice are highly susceptible to convulsive seizures upon "tossing" stimulation. The levels of excitatory (e.g. glutamate and aspartate) and inhibitory amino acids [e.g. gamma-amino-butyrate (GABA)] were examined in discrete regions of stimulated El mice [El(+)], non-stimulated El mice [El(-)] and ddY mice, which do not have convulsive disposition. In comparison with ddY, a general increased levels of aspartate, glutamate, glutamine, and taurine were detected in brain regions of El(-). The levels of GABA and glycine were almost the same in ddY and El(-). Compared to El(+), the levels of aspartate, glutamate, glutamine, and GABA in El(-) were either the same or higher. In the case of taurine and glycine, the levels in El(-) were either the same or lower than El(+). Alanine is special in that El(-) have a higher level than El(+) in hippocampus but lower in cerebellum. Furthermore, while marked changes were registered in several brain regions, none of the amino acids investigated showed any significant differences in the hypothalamus of three different groups of mice.

Inhibitory and excitatory amino acids in cerebrospinal fluid of chronic epileptic patients

We studied the levels of excitatory and inhibitory amino acids in the cerebrospinal fluid (CSF) of 28 epileptic patients (24 with partial type seizures, 4 with primary generalized seizures) and 12 controls. The levels of aspartate were 63% (p less than 0.01), glutamine 129% (p less than 0.001), and homocarnosine 127% (p less than 0.005) that of controls. The concentrations of glutamate, asparagine, total GABA, free GABA, taurine, and glycine did not differ between epileptic patients and controls. Patients with partial epilepsy had a pattern of amino acids in CSF similar to that in patients with primary generalized seizures. In the present study we did not observe increased excitation or decreased inhibition in the seizure-active brains of epileptics, as far as the CSF levels of amino acids reflect their levels in the brain.

CSF gradients for amino acid neurotransmitters

Amino acid concentrations were measured in CSF samples obtained by lumbar puncture in 51 patients, cervical puncture in 16 patients, spinal drains in nine patients, ventricular taps in five patients and from below a spinal block in six patients. There was evidence of a rostrocaudal gradient for GABA and taurine and a reverse gradient for alanine and asparagine. Lumbar CSF glycine concentrations rose with increasing age whilst GABA concentrations fell. Women had significantly lower concentrations of asparagine and glutamine and elevated taurine compared to men. The influence of biological factors and gradients must be taken into account before the interpretation of changes in CSF amino acid concentrations.

Aspartic acid aminotransferase activity is increased in actively spiking compared with non-spiking human epileptic cortex

Increased concentration of the excitatory neurotransmitter aspartic acid in actively spiking human epileptic cerebral cortex was recently described. In order to further characterise changes in the aspartergic system in epileptic brain, the behaviour of aspartic acid aminotransferase (AAT), a key enzyme involved in aspartic acid metabolism has now been examined. Electrocorticography performed during surgery was employed to identify cortical epileptic spike foci in 16 patients undergoing temporal lobectomy for intractable seizures. Patients with spontaneously spiking lateral temporal cortex (n = 8) were compared with a non-spiking control group (n = 8) of patients in whom the epileptic lesions were confined to the hippocampus sparing the temporal convexity. Mean activity of AAT in spiking cortex was significantly elevated by 16-18%, with aspartic acid concentration increased by 28%. Possible explanations for the enhanced AAT activity include increased proliferation of cortical AAT-containing astrocytes at the spiking focus and/or a generalised increase in neuronal or extraneuronal metabolism consequent to the ongoing epileptic discharge. It is suggested that the data provide additional support for a disturbance of central excitatory aspartic acid mechanisms in human epileptic brain.

GABA and amino acid concentrations in lumbar CSF in patients with treated and untreated epilepsy

Lumbar free CSF GABA and amino acid concentrations were measured in 43 patients with newly diagnosed untreated epilepsy and 26 patients with chronic drug-resistant epilepsy. The results were compared with those from 51 control patients. No differences in free CSF GABA concentration could be detected between patients with epilepsy, either treated or untreated, and controls. Untreated patients with primary generalised epilepsy and partial seizures had similar free CSF GABA concentrations. These results would not support the hypothesis that patients with epilepsy have a global disturbance of GABA function. CSF taurine, asparagine, aspartate, glycine and alanine were significantly reduced in patients with epilepsy compared to the control population.

Neurotransmitter glutamate: its clinical importance

Excitatory amino acid glutamate has several important functions in the mammalian central nervous system (CNS). This review focuses on the transmitter role of glutamate and discusses anatomical and pharmacological data of clinical neurological relevance. Experimental and clinical conditions which have been associated with altered content, uptake, membrane binding or release of glutamate in the CNS are discussed. Such conditions include, epilepsy, disorders of the basal ganglia, cerebral ischemia, hypoxia, hypoglycemia, metabolic encephalopathies, olivopontocerebellar atrophy and cerebellar ataxias, amino acidopathies, mental and other neurological disorders. With the exception of a few fibre systems, it is very difficult to differentiate between glutamate and aspartate as CNS transmitters. The term glutamate is, thus, used in the sense glutamate and/or aspartate unless specifically stated.

Elevated concentrations of glutamate and aspartate in human ventricular cerebrospinal fluid (vCSF) during episodes of increased CSF pressure and clinical signs of impaired brain circulation

In the ventricular cerebrospinal fluid (vCSF) of 10 hydrocephalic patients the mean (+/- S.D.) concentrations of glutamate and asparate were 2.9 +/- 0.2 and 0.2 +/- 0.2 microM, respectively. Significantly higher concentrations of these amino acids were found in two patients (glutamate 37.8 and 22.4 microM, aspartate 2.2 and 0.6 microM) with symptoms of impaired brain tissue perfusion, i.e. relative ischemia due to severely increased intraventricular CSF pressure. Our results are consistent with recent experiments in rats showing increased extracellular concentrations of glutamate and aspartate during transient cerebral ischemia.