The central autonomic network: functional organization, dysfunction, and perspective

Two cases of reiterated Horner's syndrome after lumbar epidural block

We describe two young men with low back pain, who were given repeat lumbar epidural blocks for treatment of pain. They both developed reiterated unilateral Homer's syndrome. Computer tomography and myelography of the lumbar spine prior to the intervention showed signs of suspect disc herniation and sequelae after previous surgery.

Brain stem stroke causing baroreflex failure and paroxysmal hypertension

BACKGROUND

Paroxysmal neurogenic hypertension has been associated with a variety of diseases affecting the brain stem but has only rarely been reported after brain stem stroke. The mechanism is thought to involve increased sympathetic activity and baroreflex dysfunction. We undertook microneurographic recordings of muscle sympathetic nerve activity (MNSA) during beat-to-beat blood pressure (BP) monitoring to investigate this hypothesis.

CASE DESCRIPTION

We investigated a 75-year-old woman who developed paroxysmal hypertension (BP 220/110 mm Hg) after a large left-sided medullary infarct. The paroxysms were triggered by changes in posture and were accompanied by tachycardia, diaphoresis, and headache. Serum catecholamines were substantially increased (norepinephrine level, 23.9 nmol/L 9 days after stroke; normal level, <3.8 nmol/L), and heart rate variability, measured by spectral analysis, was decreased in both low- and high-frequency domains (0.04 and 0.06 ms(2), respectively; normal level, 0.14+/-0.02 ms(2)). MNSA was increased in frequency (61 bursts per minute; normal level, 34+/-18 bursts per minute), and the burst amplitude was not inversely related to diastolic BP. BP and MNSA responses to cold pressor and isometric handgrip stimuli were intact.

CONCLUSIONS

Extensive unilateral infarction of the brain stem in the region of the nucleus tractus solitarius may result in partial baroreflex dysfunction, increased sympathetic activity, and neurogenic paroxysmal hypertension.

Central nervous system neurons labeled following the injection of pseudorabies virus into the rat prostate gland

BACKGROUND

The human prostate gland plays an important role in male fertility and is involved in different functional pathologies of the male lower urinary tract (LUT). The role of the prostate in these medical disorders is mainly unknown. Traditional surgical therapeutic attempts often fail to help these patients. For years, the clinical sciences have been stagnating due to a lack of basic science knowledge. Investigations into neuroanatomy and neurophysiology are urgently needed. Therefore, the neuroanatomy of the prostate gland in an experimental setup was explored. Recent progress in neuroscience methodology allows a transneuronal tracing by using a self-amplifying virus tracer, pseudorabies virus (PRV).

METHODS

Sixty-two individual adult male Sprague-Dawley rats were used for retrograde transneuronal mapping of the spinal cord and brain stem after PRV-injection and control experiments. A PRV-tracer (5 microl, 1 x 10(8) pfu/ml) was injected into the prostate gland. After a survival time of 72, 96, or 120 hr, the animals were sacrificed. Brain and spinal cord were harvested via a dorsal laminectomy. After cutting on a freezing microtome, the tissue was immunostained for PRV.

RESULTS

PRV-positive cells were found within the sacral (S1-S2) and the thoracolumbar (T13-L2) spinal cord. At the supraspinal level, positive cells were found within the following regions: nucleus raphe, lateral reticular formation, nucleus gigantocellularis, A5 noradrenergic cell region, locus coeruleus, pontine micturition center, hypothalamus, medial preoptic region, and periaquaductal gray.

CONCLUSIONS

This is the first investigation on the central innervation of the prostate gland showing a broad central representation of neurons involved in the control of the prostate gland. It is obvious, comparing data from the literature, that there is a broad overlap in the innervation of pelvic visceral organs (bladder, rectum, and urethra). The appreciation of these neuroanatomical circumstances allows a growing understanding of common urological pathologies within the pelvis (pelvic pain, lower urinary tract, and bowel dysfunction).

Pathophysiology and differential diagnosis of neurocardiogenic syncope

Syncope, the transient loss of consciousness and postural tone, is both a sign and a syndrome and may result from very diverse causes. Over the last decade, considerable attention has been focused on neurocardiogenic syncope, also known as vasovagal syncope. Research has demonstrated that the disorder is one aspect of a much broader group of disturbances of the autonomic nervous system that may lead to hypotension, orthostatic intolerance, and ultimately syncope. Recent discoveries have caused us to reevaluate our classification of autonomic disorders and to develop a new system that reflects current knowledge. A basic understanding of syncope and related disorders is essential to diagnosis and proper treatment. This article provides an overview of these conditions, their pathophysiology, and diagnosis.

Lateral hypothalamic serotonin inhibits nucleus accumbens dopamine: implications for sexual satiety

Dopamine (DA) is released in several brain areas, including the nucleus accumbens (NAcc), before and during copulation in male rats. DA agonists administered into this area facilitate, and DA antagonists inhibit, numerous motivated behaviors, including male sexual behavior. Serotonin (5-HT) is generally inhibitory to male sexual behavior. We reported previously that 5-HT is released in the anterior lateral hypothalamic area (LHA(A)) and that a selective serotonin reuptake inhibitor microinjected into that area delayed and slowed copulation. Our present results, using high temporal resolution microdialysis, (1) confirm previous electrochemical evidence that extracellular levels of DA increase in the NAcc during copulation and decrease during the postejaculatory interval (PEI) and (2) reveal that LHA(A) 5-HT can inhibit both basal and female-elicited DA release in the NAcc. These findings suggest that the neural circuit promoting sexual quiescence during the PEI includes serotonergic input to the LHA(A), which in turn inhibits DA release in the NAcc. These findings may also provide insights concerning the inhibitory control of other motivated behaviors activated by the NAcc and may have relevance for understanding the sexual side effects common to antidepressant medications.

Regional cerebral blood flow during temporal lobe seizures associated with ictal vomiting: an ictal SPECT study in two patients

PURPOSE

Ictal vomiting represents a rare clinical manifestation during seizures originating from the temporal lobes of the nondominant hemisphere. The precise anatomic structures responsible for generation of ictal vomiting remain to be clarified. Ictal single photon emission computed tomography (SPECT), which allows one to visualize the three-dimensional dynamic changes of regional cerebral blood flow (rCBF) associated with the ongoing epileptic activity, should be useful to study the brain areas activated during ictal vomiting.

METHODS

We performed ictal Tc-HMPAO SPECT scans in two patients with mesial temporal lobe epilepsy (MTLE) whose seizures were characterized by ictal retching and vomiting. MTLE was documented by typical clinical seizure semiology, interictal and ictal EEG findings, hippocampal atrophy on magnetic resonance imaging (MRI) scan, and a seizure-free outcome after selective amydalohippocampectomy. In both patients, seizures originated in the nondominant temporal lobe. We obtained accurate anatomic reference of rCBF changes visible on SPECT by a special coregistration technique of MRI and SPECT. We used ictal SPECT studies in 10 patients with MTLE who had seizures without ictal vomiting as controls.

RESULTS

In the two patients with ictal vomiting, we found a significant hyperperfusion of the nondominant temporal lobe (inferior, medial, and lateral superior) and of the occipital region on ictal SPECT. In patients without ictal vomiting, on the contrary, these brain regions never were hyperperfused simultaneously.

CONCLUSIONS

Ictal SPECT provides further evidence that activation of a complex cortical network, including the medial and lateral superior aspects of the temporal lobe, and maybe the occipital lobes, is responsible for the generation of ictal vomiting.

The electrical and magnetical cerebral responses evoked by electrical stimulation of the esophagus and the location of their cerebral sources

OBJECTIVES

After electrical stimulation of the esophagus cerebral responses are recordable, their cortical source is under discussion. Brain mapping using electroencephalography recordings demonstrated partially controversial results. Sources of evoked responses can be localized more easily using magnetoencephalography than electroencephalography.

METHODS

We examined 22 volunteers by recording electrical somatosensory potentials after electrical stimulation of the esophagus. In 9 of these 22 subjects additional recording of magnetic fields was performed and the sources of the evoked magnetic fields were computed.

RESULTS

The evoked potentials after electrical stimulation of the esophagus had a similar latency as the previously published data. The source localization done by magnetoencephalography suggest that first a region of the postcentral gyrus is activated which is temporo-lateral to the primary somatosensory cortex of the pharynx. This region is suggested to be the primary somatosensory region of the esophagus. This source was followed by a source in the parietal operculum thought being part of the secondary somatosensory cortex. Simultaneously the insular cortex was activated pointing to a parallel neuronal pathway to the central autonomic nervous system.

CONCLUSION

After electrical stimulation of the esophagus somatosensory cortical areas of the temporal postcentral gyrus and the operculum are activated. In parallel activation of the insular cortex as part of the central autonomic network was found.

Presence of mu-opioid receptors in targets of efferent projections from the central nucleus of the amygdala to the nucleus of the solitary tract

Opioids acting at mu-opioid receptors (MORs) within the nucleus of the solitary tract (NTS) potently modulate autonomic functions that are also known to be influenced by inputs from the central nucleus of the amygdala (CEA). In addition, many of the physiological effects of MOR agonists have been attributed to interactions with neurons that contain gamma-aminobutyric acid (GABA), one of the neurotransmitters present in CEA-derived terminals and their targets in the medial NTS. Together, these observations suggest that MORs are present at pre- or postsynaptic sites within the CEA to NTS circuitry. To test this hypothesis, we combined anterograde transport of biotinylated dextran amine (BDA) with immunogold-silver localization of an antipeptide antiserum against the MOR in the NTS of adult rats. In animals receiving bilateral CEA injections of BDA, anterogradely labeled axons were seen throughout the rostrocaudal NTS. Electron microscopy of the medial NTS at rostral and intermediate levels showed anterograde BDA-labeling in many small unmyelinated axons and axon terminals, none of which contained detectable MOR. The BDA-labeled axon terminals formed mainly symmetric, inhibitory-type synapses with somata and dendrites. Over half of the somatic and approximately 10% of the dendritic targets showed nonsynaptic plasmalemmal immunogold labeling for MOR. The BDA-labeled axon terminals were also frequently apposed by other small axons that contained MORs. These results suggest that within the medial NTS, MOR agonists modulate the postsynaptic inhibition produced by CEA afferents and also play a role in the presynaptic release of other neurotransmitters.

Management of vasovagal syncope

Vasovagal syncope is a common disorder of autonomic cardiovascular regulation that can be very disabling and result in a significant level of psychosocial and physical limitations. The optimal approach to treatment of patients with vasovagal syncope remains uncertain. Although many different types of treatment have been proposed and appear effective based largely on small nonrandomized studies and clinical series, there is a remarkable absence of data from large prospective clinical trials. However, based on currently available data, the pharmacologic agents most likely to be effective in the treatment of patients with vasovagal syncope include beta blockers, fludrocortisone, and alpha-adrenergic agonists. In this article, we provide a summary of the various therapeutic options that have been proposed for vasovagal syncope and review the clinical studies that form the basis of present therapy for this relatively common entity.

Clinical disorders of the autonomic nervous system associated with orthostatic intolerance: an overview of classification, clinical evaluation, and management

The disorders of autonomic control associated with orthostatic intolerance are a diverse group of infirmities that can result in syncope and near syncope (as well as a host of other complaints). A basic understanding of these disorders is essential to both diagnosis and proper treatment. These infirmities are not new, what has changed is our ability to recognize them. It has been said that "the world undergoes change in the human consciousness. As this consciousness changes, so does the world." On going studies will continue to help better define the broad spectrum of these disorders, and to elaborate better diagnostic and treatment modalities.

Respiratory sinus arrhythmia of brainstem lesions

In this pilot study we investigated the hypothesis that intrinsic and extrinsic brainstem lesions situated within the pontomedullary region would effect the integrity of respiratory sinus arrhythmia. The study sample consisted of three patients with anatomic brainstem abnormalities associated with isolated Chiari I malformation, Chiari II malformation with syringobulbia, and achondroplasia with cervicomedullary compression. They were compared to an age- and sex-matched control group of nine patients. Each subject's electrocardiogram was recorded in a quiet room and digitized by a personal computer during five 1-minute periods. R-R intervals within each 1-minute period were converted to heart rate in 120 successive 0.5-second intervals. The resultant heartrate time series was converted to its underlying frequency composition by a fast Fourier transform and averaged across minutes. Respiratory sinus arrhythmia was defined as the variability in the time series over a frequency range (0.096 to 0.48 Hz) corresponding to a range of respiratory rates from 6 to 30 breaths per minute. Analysis revealed a significant reduction in respiratory sinus arrhythmia (P < .05), defined as the summated area under the curve, with a mean for controls of 35.42+/-28.13 SD and for subjects of 17.20+/-11.50 SD. There was a gradient of abnormality noted, with the mildest deviation in respiratory sinus arrhythmia for the patient with isolated Chiari I malformation and maximum deviation seen in the patient with extrinsic cervicomedullary compression.

Cardiovascular changes associated with spontaneous and evoked K-complexes

This study examines the relationship between blood pressure and spontaneous and sound-evoked K-complexes (KCs) during stage 2 NREM sleep, in 8 volunteers studied by intraarterial blood pressure (BP) monitoring and polysomnography. A robust oscillation of blood pressure with a period of 16-30 s (Mayer waves) was seen in all subjects. Spontaneous KCs predominantly occurred during a drop (downward slope) in blood pressure. Randomly administered sound stimuli were more likely to evoke a KC if the stimulus was given during a downward slope of BP. During the last 20 s prior to a sound-evoked KC, the mean drop in systolic BP was 0.3 mmHg, and evoked and spontaneous K-complexes were preceded by a mean drop in BP of 1.9 and 2.7 mmHg, respectively. Finally, K-complexes, either spontaneous or evoked, during the first 6 s, induced a rise in systolic BP. The results indicate that if the BP falls during stage 2 NREM sleep, there is a greater likelihood that an external stimulus will evoke a K-complex and that spontaneous K-complexes may occur more frequently as well. Spontaneous and evoked K-complexes may play a role in the control of BP during NREM sleep.

Autonomic and hormonal ictal changes in gelastic seizures from hypothalamic hamartomas

OBJECTIVES

We describe two patients with hypothalamic hamartoma and gelastic seizures.

METHODS

We performed ictal neurophysiological studies with polygraphic recordings of autonomic parameters and hormonal ictal plasma concentration measurements.

RESULTS

Ictal recordings showed a stereotyped modification of autonomic parameters: increase in blood pressure and heart rate, peripheral vasoconstriction and modification of respiratory activity. At seizure onset, the norepinephrine plasma level was high and epinephrine unchanged, whereas prolactin and adrenocorticotropic hormone were increased in both cases. Growth hormone and cortisol plasma concentrations in each patient showed a different response to seizures.

CONCLUSIONS

These data provide evidence that gelastic seizures are accompanied by an abrupt sympathetic system activation, probably due to the direct paroxysmal activation of limbic and paralimbic structures or other autonomic centres of the hypothalamus and medulla.

The parabrachial nucleus mediates the decreased cardiac baroreflex sensitivity observed following short-term visceral afferent activation

Previous investigations have provided evidence demonstrating that the extracellular release of glutamate into the parabrachial nucleus was significantly enhanced following visceral afferent activation. This period of enhanced glutamate release into the parabrachial nucleus corresponded to a time during which the pressor response to a bolus phenylephrine injection was significantly enhanced, and the reflex bradycardia was attenuated. This decrease in the sensitivity of the baroreflex is suggestive of an enhanced sympathetic tone as a result of the vagal stimulation. The present investigation was done to determine if the decreased baroreflex sensitivity observed following short-term vagal stimulation is mediated by an increase in sympathetic activity and was dependent on the parabrachial synapse. Male Sprague-Dawley rats were anaesthetized with sodium thiobutabarbitol and instrumented to monitor blood pressure and heart rate and for the placement of a stimulating electrode on the left cervical vagus nerve. Femoral arterial blood samples were taken before, during and after 2 h of vagal stimulation which were later assayed for plasma catecholamines. The results showed that plasma norepinephrine levels decreased during, and were significantly elevated immediately following termination of the vagal stimulation, indicative of an increase in sympathetic tone. To determine if the parabrachial nucleus is involved in mediating an enhanced sympathetic activity following vagal stimulation, a second group of animals underwent an identical surgical preparation, vagal stimulation and blood sampling protocol with the addition of bilateral microinjections of either the reversible anaesthetic, lidocaine, or saline into the parabrachial nucleus. The results showed that reversible blockade of the parabrachial nucleus prior to the onset of the vagal stimulation was effective in blocking both the elevation in plasma norepinephrine levels and the depressed baroreflex sensitivity previously observed following 2 h of vagal stimulation. These results suggest that the parabrachial nucleus mediated the sympathoexcitation and consequent depression in baroreflex sensitivity observed following visceral afferent activation.

Postoperative chronic pain and bladder dysfunction: windup and neuronal plasticity--do we need a more neurological approach in pelvic surgery?

PURPOSE

Cases of combined symptoms of dysfunctional voiding and associated pelvic discomfort are difficult diagnostic and therapeutic challenges. Surgical solutions not uncommonly fail to relieve those symptoms. We determine why these symptoms persist postoperatively.

MATERIALS AND METHODS

Four cases of ureteral injury during gynecological laparoscopic procedures for pelvic/menstrual pain are presented. The cases are reviewed for their severity and similarity in presenting symptoms, complications and long-term consequences.

RESULTS

In all cases light pain symptoms and/or dysfunctional voiding problems that existed before the initial surgery escalated severely after corrective pelvic surgery.

CONCLUSIONS

There are established neurophysiological mechanisms that would explain the observed increase in pain after surgical manipulation of the pelvis. Windup and changes in neuronal plasticity are direct consequences of wounding and/or neural injury to the central nervous system. These principles are important for surgeons to appreciate due to the impact they can have on the outcomes of surgery. Blocking the sensory input into the spinal cord, inherent to every surgical procedure, through use of local anesthetics, that is preemptive anesthesia, before creation of a wound provides the greatest protection against escalation of symptoms. Thorough evaluation of all patients before pelvic surgery is recommended to identify high risk groups (preexisting pain, voiding syndromes).

Cellular orientation of atrial natriuretic peptide in the human brain

Many peptide hormones and neurotransmitters have been detected in human neuronal tissue. The localisation of atrial natriuretic peptide (ANP) in the human brain was considered to be both interesting and relevant to the understanding of neurochemistry and brain water-electrolyte homeostasis. This vasoactive peptide hormone has been localised in rat and frog neuronal tissue. In the present study, we report the immunohistochemical localisation of ANP in autopsy samples of human brain tissue employing the avidin-biotin-peroxidase complex technique, using an antibody against a 28 amino acid fragment of human ANP. The most intense staining of immunoreactive ANP was detected in the neurones of preoptic, supraoptic and paraventricular nuclei of the hypothalamus, epithelial cells of the choroid plexus and ventricular ependymal lining cells. Immunoreactive neurones were also observed in the median eminence, lamina terminalis, infundibular and ventromedial nuclei of the hypothalamus, and in neurones of the brain stem, thalamic neurones and some neurones of the caudate nucleus. The network of ANP cells in numerous hypothalamic centres may regulate the salt and water balance in the body through a hypothalamic neuro-endocrine control system. ANP in the brain may also modulate cerebral fluid homeostasis by autocrine and paracrine mechanisms.

Estimation of nonlinear couplings on the basis of complexity and predictability--a new method applied to cardiorespiratory coordination

Nonlinear coordination is an essential property of the complex functioning of the autonomic nervous system. Therefore, the coupled behavior of heart rate fluctuations (HRF) and respiratory movements (RM) was analyzed on the basis of their joint reconstruction in the phase space. Independence measures of complexity and predictability were approximated from the correlation integrals which enabled the strength of cardiorespiratory couplings to be quantified. These measures were validated in a simulation study of two coupled nonlinear oscillators in dependence on their coupling strength and respective synchronization effects. The cardiorespiratory coordination during quiet sleep and active sleep of newborn piglets was quantified by means of the proposed independence measures of complexity and predictability. The difference of those measures between the sleep states investigated was more significant than the difference of the respective linear coherence peaks.

Review article: heart rate and blood pressure control in vasovagal syncope

Vasovagal syncope is characterized by transient failure of usually reliable physiologic mechanisms responsible for maintaining both systemic arterial pressure and cerebral blood flow. Two circulatory phenomena are almost universally present: systemic arterial vasodilation and bradycardia. A third phenomenon, cerebrovascular constriction, has also been described but its contribution to the faint is less well established. The neural reflex pathways responsible for triggering the circulatory changes in the vasovagal faint are incompletely understood, but have recently been the subject of renewed interest. In part, this interest probably stems from the frequency with which vasovagal symptoms are now recognized to be the cause of fainting spells. Additionally, however, there is an increasingly recognized need to develop treatment strategies for those affected patients in whom recurrent vasovagal symptoms are particularly troublesome. It is the goal of this discussion to focus on those aspects of circulatory control, and in particular on potential interactions among certain neural and humoral systems, which may contribute to the inappropriate physiologic responses associated with the vasovagal faint.

Pain as a complication of HIV disease

Pain as a symptom is common to many pathologic conditions. At its most elementary level, it is a signal from peripheral nerves with specialized receptors that there is a change in the local environment, such as pressure, pH, temperature, or some other noxious stimulus, that can be detrimental to function. Pain is particularly prevalent in patients with HIV infection. The assessment, evaluation, and treatment of pain should be an integral part of comprehensive patient care.

Sleep-onset rapid eye movement periods in neuropsychiatric disorders: implications for the pathophysiology of psychosis

This paper reviews the literature describing the occurrence of sleep-onset rapid eye movement periods in narcolepsy, schizophrenia, psychotic depression, and delirium tremens; the association of narcolepsy with psychotic disorders; the neuropathology of the brainstem in narcolepsy and schizophrenia; and other behavioral disorders resulting from probable brainstem pathology. These findings suggest that some forms of psychosis are a manifestation of pathophysiological changes in the brainstem. Some implications of this hypothesis for the treatment of psychoses are discussed. Future research should investigate psychoses and the psychobiological correlates of such biological markers as sleep-onset rapid eye movement periods across diagnostic categories.

Modulation of the cardiac baroreflex following reversible blockade of the parabrachial nucleus in the rat

The parabrachial nucleus (PBN) has a prominent anatomical connection with the nucleus of the solitary tract as well as other central baroreflex centres which suggests a role for the PBN in the regulation of this cardiovascular reflex. This study examined the effects of a reversible, bilateral blockade of the PBN on the cardiac baroreflex. Male Sprague-Dawley rats were anesthetized with sodium butabarbitol and instrumented to monitor blood pressure and heart rate and for the intravenous administration of drugs. The cardiac baroreflex was evoked using bolus intravenous injections of phenylephrine (PE) and sodium nitroprusside (NaNp) at various doses and a graph of baroreflex sensitivity was constructed. Bilateral microinjections of the reversible anesthetic, lidocaine (5%, 300 nl), into the PBN did not significantly change baseline blood pressure or heart rate when compared to microinjections of saline (0.9%, 300 nl) into the PBN. The pressor or depressor responses evoked by bolus injections of PE or NaNp, respectively, were not significantly affected by the bilateral pretreatment of the PBN with lidocaine when compared to saline controls. However, approximately 30 min following lidocaine injection, the amplitudes of both the evoked-reflex bradycardia and reflex tachycardia were significantly increased by approximately 98%. The cardiovascular responses to various doses of PE and NaNp were graphed and baroreflex sensitivity curves were constructed. This graph showed an increased slope of the baroreflex sensitivity curve following lesions of the PBN. Reflex changes in heart rate returned to pre-lidocaine injection levels after approximately 2 h. The results of the present investigation suggest that the PBN participates in the modulation of the cardiac baroreflex which in turn suggests a role for this nucleus in the central integration of cardiovascular reflex function.

AAEM minimonograph #48: autonomic nervous system testing

The autonomic nervous system maintains internal homeostasis by regulating cardiovascular, thermoregulatory, gastrointestinal, genitourinary, exocrine, and pupillary function. Testing and quantifying autonomic nervous system function is an important but difficult area of clinical neurophysiology. Tests of parasympathetic cardiovagal regulation include heart rate analysis during standing (the 30:15 ratio), heart rate variation with deep breathing, and the Valsalva ratio. Tests of sympathetic adrenergic vascular regulation include blood pressure analysis while standing, the Valsalva maneuver, sustained handgrip, mental stress, and cold water immersion. Tests of sympathetic cholinergic sudomotor function include the sympathetic skin response, quantitative sudomotor axon reflex test, sweat box testing, and quantification of sweat imprints. Pupil function is tested pharmacologically and with pupiilographic techniques. Tests of gastrointestinal and genitourinary function do not satisfactorily isolate autonomic regulation from their other functions. The available tests have various sensitivities and ease of administration. They are typically administered in a battery of multiple tests, which improves sensitivity and reliability, and allows probing of various autonomic functions.

Magnetic brain imaging of extinction processes in human classical conditioning

By recording neuromagnetic events during aversive classical conditioning, we examined the extinction of a previously described conditioned response. Averaging over non-reinforced exposures to the conditioned stimulus revealed magnetic activity in the secondary somatosensory and insular cortices, appearing between 110 and 140 ms after the omitted unconditioned electric shock. We suggest this activity to be elicited by the discrepancy between shock expectancy and perceptual processes associated with the omission of the unconditioned stimulus, reflecting one of several brain processes in extinction.

Concurrent subarachnoid haemorrhage and myocardial injury

PURPOSE

Subarachnoid haemorrhage is frequently associated with myocardial injury and dysfunction. This report describes such a case, reviews the understanding of this phenomenon, and discusses the implications for timing of surgical clipping of intracranial aneurysm in patients with concurrent myocardial damage.

CLINICAL FEATURES

A 64-yr-old women presented with syncope and congestive heart failure. A diagnosis of subarachnoid haemorrhage was made three days following the initial diagnosis of myocardial infarction. The patient presented for clipping of an intracranial aneurysm on day 36, after her cardiac status had stabilized. No new myocardial ischaemic events occurred, either intra-operatively or post-operatively. Ultimate neurological recovery was poor.

CONCLUSIONS

This case report demonstrates four important aspects of the clinical course of patients with concurrent subarachnoid haemorrhage and myocardial damage: 1) On presentation, cardiac features may predominate, and delay diagnosis and treatment of the underlying subarachnoid haemorrhage. 2) Left ventricular dysfunction, although dramatic, is usually transient. 3) There is confusion regarding the appropriate cardiac risk assessment and management in such patients when presenting for surgery. 4) Long-term morbidity is most often related to neurological, not medical, complications.

Neurally mediated syncopal syndromes: pathophysiological concepts and clinical evaluation

The neurally mediated syncopal syndromes encompass a number of apparently related disturbances of reflex cardiovascular control characterized by transient inappropriate bradycardia and/or vasodilation of various arterial and venous beds. Certain of these syndromes (e.g., carotid sinus syndrome, postmicturition syncope) are encountered occasionally in clinical practice, whereas others are quite rare (e.g., swallow syncope). On the other hand, vasovagal syncope occurs so frequently, that as a group, the neurally mediated syncopal syndromes are among the most important causes of syncope. The pathophysiology of the neurally mediated syncopal syndromes is incompletely understood, but can be considered in terms of four basic elements: (1) the afferent limb; (2) central nervous system (CNS) processing; (3) the efferent limb; (4) feedback loops. The afferent limb consists of several peripheral and CNS trigger sites and the associated connections to medullary cardiovascular centers. CNS processing and efferent signals result in both bradycardia, which may be marked or relative, and vasodilatation. Failure of baroreceptor feedback controls to prevent hypotension is important in facilitating development of symptomatic hypotension. Head-up tilt table testing has become the diagnostic technique of choice for clinically assessing susceptibility to neurally mediated syncope, particularly of the vasovagal type. Most studies suggest that such testing discriminates relatively well between symptomatic patients and asymptomatic control subjects, of whom 10%-15% have a false-positive test results. Sensitivity of tilt table testing is more difficult to evaluate because there is no accepted diagnostic gold standard. However, sensitivity (measured against a classic presentation) has been estimated to range from 32%-85%, with most reports favoring the higher end of this range. Treatment strategies for neurally mediated syncope remain controversial. Many single episodes do not warrant treatment unless physical injury has occurred, or a high risk occupation or avocation is involved. Tilt test exposure alone may prove beneficial in educating patients with recurrent syncope to recognize warning signs of an imminent faint. Large controlled clinical studies have not been performed to test the efficacy of pharmacological therapy (e.g., beta-adrenergic blockers, disopyramide, serotonin reuptake blockers, vasoconstrictors) or pacing therapy. Such studies may be difficult to undertake due to the variable frequency of spontaneous symptoms and apparent long periods of remission. Nonetheless, many investigators and clinicians have come to rely on these agents, and on tilt testing to guide treatment decisions. Studies employing careful correlation of long-term clinical follow-up with results of early and perhaps later repeat tilt studies are still needed.

Orthostatic hypotension due to suppression of vasomotor outflow after amphetamine intoxication

Ten hours after ingestion of amphetamines, a previously healthy 17-year-old female adolescent experienced dizziness on standing. Examination revealed pronounced drowsiness and severe orthostatic hypotension. Assessment of arterial baroreflex function suggested that suppressed sympathetic vasomotor drive was the cause of the orthostatic hypotension. Within 3 days, the baroreflex failure resolved spontaneously. To our knowledge, suppressed vasomotor outflow after ingestion of amphetamines has been previously observed only in animal studies.

Hypertension-associated hypalgesia. Evidence in experimental animals and humans, pathophysiological mechanisms, and potential clinical consequences

A behavioral hypalgesia (increased response threshold to noxious stimuli) has been consistently, although not invariably, reported in spontaneous and experimental acute and chronic hypertension in the rat. Studies in human hypertension have also demonstrated a diminished perception of pain, assessed as pain thresholds or ratings. The sensitivity to painful stimuli correlated inversely with blood pressure levels, and this relationship extended into the normotensive range. Evidence in humans and rats points to a role of the baroreflex system in modulating nociception. In the rat, blood pressure-related antinociception may be due to attenuated transmission of noxious stimuli at the spinal level secondary to descending inhibitory influences that are projected from brain stem sites involved in cardiovascular regulation and that may depend on baroreceptor activation and/ or on a central "drive." Both endorphinergic and noradrenergic central neurons (the latter acting through postsynaptic alpha 2-receptors) have been shown to be involved, and other mediators probably also play a role. Functionally, blood pressure-related antinociception may represent an aspect of a more-complex coordinated adaptive response of the body to "stressful" situations. It is still uncertain whether in human essential hypertension hypalgesia is secondary to elevated blood pressure or whether both depend on some common mechanism. Studies on the effect of hypotensive treatment are too few to allow conclusions. According to one hypothesis, the reduction in pain perception caused by baroreceptor activation secondary to blood pressure elevation may represent a rewarding mechanism that may be reinforced with repeated stress and may be involved in the development of hypertension in some individuals. Hypertension-associated hypalgesia may have clinically relevant consequences, especially in silent myocardial ischemia and unrecognized myocardial infarction, both of which are more prevalent in hypertensive individuals.

Syncope and the autonomic nervous system

The autonomic nervous system plays a central role in the maintenance of hemodynamic stability. Dysfunction of this complex regulatory system can lead to the development of loss of consciousness. This article summarizes our current understanding of the role of the autonomic nervous system in maintaining a stable blood pressure and heart rate under normal and abnormal physiologic conditions. The role of baroreceptors, mechanoreceptors, chemoreceptors, vascular reactivity, and the interaction of these sensor systems with the central nervous system as a whole are reviewed. Current concepts related to the mechanisms of unexplained syncope and the "state-of-the-art" diagnostic and treatment options are also discussed.

Electrophysiological tests of autonomic function in patients with idiopathic autonomic failure syndromes

Three electrophysiological tests of autonomic function were performed in patients with autonomic nervous system dysfunction to define test sensitivities and specificities. The skin sympathetic response, Valsalva ratio, and heart rate variation with deep breathing were studied in 10 patients with multiple system atrophy (MSA) and in 7 patients with pure (also called progressive or primary) autonomic failure (PAF); control subjects were 17 normal individuals of similar age. Thirteen patients had abnormal skin sympathetic responses, and 16 had abnormal Valsalva ratios. Fourteen patients had an abnormal variation of the heart rate with deep breathing. Taking the three tests together, binary logistic regression for distinguishing between patients and normal subjects correctly classified 91% of the 33 individuals for whom there were complete data with sensitivity of 88% and specificity of 94%. However, only 69% of the patients could be correctly classified by a logistic regression for discriminating between MSA and PAF. Electromyography (EMG) studies showed that 7 of 8 patients with MSA but only 2 of 7 patients with PAF (both multiparous women) had denervation of the rectal sphincter muscle. The EMG study is, therefore, valuable in men, but has a high false positive rate in women, probably because of pudendal nerve injury from parturition.

Altered c-fos expression in the parabrachial nucleus in a rodent model of CFA-induced peripheral inflammation

Increases in the expression of immediate early genes have been shown to occur in the lumbar spinal cord dorsal horn after peripheral inflammation. Given that the pontine parabrachial nucleus has been implicated in nociceptive as well as antinociceptive processes and is reciprocally connected with the spinal cord dorsal horn, it seems likely that peripheral inflammation will cause alterations in immediate early gene expression in this nucleus. To test this hypothesis we examined cFos-like immunoreactivity in a rodent complete Freund's adjuvant-induced peripheral inflammatory model of persistent nociception. Unilateral hind paw injections of complete Freund's adjuvant produced inflammation, hyperalgesia of the affected limb, and alterations in open field behaviors. Immunocytochemical analysis demonstrated a bilateral increase in cFos-like immunoreactivity in the lateral and Kolliker-Fuse subdivisions of the parabrachial nucleus at 6 and 24 hours postinjection and an ipsilateral decrease below basal levels in the Kolliker-Fuse subdivision at 96 hours postinjection when compared to saline controls. Taken together, these results suggest that select parabrachial neurons are activated by noxious somatic inflammation. These active parabrachial neurons are likely to participate in ascending nociceptive and/or descending antinociceptive pathways.

Respiratory sinus arrhythmia in patients with Prader-Willi syndrome

In this investigation, we sought to further test the hypothesis that parasympathetic deficiency exists among persons with Prader-Willi syndrome, by examining respiratory sinus arrhythmia. The study sample comprised two groups of patients: 14 subjects with Prader-Willi syndrome and 14 age- and sex-matched controls. Each subject's electrocardiogram was recorded in a quiet room and digitized by a personal computer during five 1-minute periods. RR intervals within each 1-minute period were converted to heart rate in 120 successive 0.5-second intervals. The resultant heart rate time series was converted to its underlying frequency composition by a fast Fourier transform and averaged across minutes. Respiratory sinus arrhythmia was defined as the variability in the time series over a frequency range (0.096 to 0.48 Hz) corresponding to a range of respiratory rates from six to 30 breaths/minute. Analysis revealed significantly less variability in the heart rates of subjects with Prader-Willi syndrome relative to age- and sex-matched controls (group x frequency bin: F = 2.26, P < .05). An analysis of covariance adjusting for body mass index differences between the groups produced identical results. These findings support the existence of a parasympathetic deficiency among subjects with Prader-Willi syndrome independent of their body mass. This is likely due to dysregulation of the central autonomic network.

Amygdala efferents form inhibitory-type synapses with a subpopulation of catecholaminergic neurons in the rat Nucleus tractus solitarius

The central nucleus of the amygdala (CNA) integrates visceral responses to stress partially through efferent projections to portions of the medial nuclei of the solitary tracts (mNTS) containing catecholaminergic neurons. To determine anatomical sites for CNA modulation of these neurons, immunoperoxidase detection of anterogradely transported Phaseolus vulgaris-leucoagglutinin (PHA-L) or biotinylated dextran amine (BDA) was combined with immunogold-silver labeling of the catecholamine-synthesizing enzyme, tyrosine hydroxylase, in adult rat mNTS. From 350 anterogradely labeled terminals identified within the intermediate mNTS, 30% formed symmetric, inhibitory-type synapses and the remainder lacked recognized junctions as seen within a single plane of section. Of the terminals forming symmetric synapses, 16% were presynaptic to tyrosine hydroxylase immunoreactive dendrites and the remainder to unlabeled dendrites. The level of tyrosine hydroxylase immunoreactivity as assessed by density of gold-silver particles was significantly lower in dendrites receiving synaptic input from CNA efferents as compared with dendrites of the same sizes (2.0 microns 2 in mean area) which received synapses from unlabeled terminals or lacked recognizable synaptic inputs. When separately examined without regard to afferent input, the medium- and larger-sized dendrites having mean cross-sectional areas of 1-3 microns 2 also contained significantly less tyrosine hydroxylase immunoreactivity than small (< 1 micron 2) dendrites. These results suggest that CNA efferents to the mNTS inhibit non-catecholamine-containing neurons and a subpopulation of catecholaminergic neurons distinguished by their low levels of tyrosine hydroxylase. The findings also indicate that small, presumably more distal, dendrites in the intermediate mNTS may synthesize and/or release catecholamines.

Cardiovascular responses to noxious stimuli during isoflurane anesthesia are minimally affected by anesthetic action in the brain

We investigated the ability of isoflurane to ablate cardiovascular responses to a noxious stimulus (dew-claw clamp) in 10 goats during isoflurane delivery throughout the body and with selective delivery to either the head or torso. Whole-body minimum alveolar anesthetic concentration (MAC) and the concentration blocking autonomic responses (MAC-BAR) were determined. Next, cranial blood (jugular vein) was drained into an oxygenator and reinfused into the head (carotid artery). In six animals (Group I) isoflurane to the torso was maintained at 0.2%-0.3%, and the cranial isoflurane concentration adjusted to determined MAC-BAR; in three animals (Group II) cranial isoflurane was maintained at 0.2%-0.3%, and the end-tidal isoflurane adjusted to determine MAC-BAR. Whole-body MAC was 1.4% +/- 0.3%; whole-body MAC-BAR was 3.7% +/- 0.4%, a concentration range associated with hypotension (46 +/- 8 mm Hg). During bypass, MAC-BAR was 5.6% +/- 2.4% for Group I (P < 0.05) and 2.2% +/- 0.7% for Group II (P < 0.05). Changes in blood pressure, but not heart rate, correlated with the isoflurane concentration, both during the whole-body period and bypass period for Groups I and II. We conclude that isoflurane suppresses the arterial blood pressure response to noxious stimuli, but only with concomitant hypotension, and that the brain has little influence on this response, as its MAC-BAR substantially exceeded whole-body MAC-BAR.

Centrally mediated ocular hypotension: potential role of imidazoline receptors

These experiments sought to: (1) determine if alpha 2/I1 agonists that are topically active on the eye have similar effects on intraocular pressure when applied to the CNS and (2) ascertain whether these agents lower IOP, in part, via central alpha 2 receptors and/or imidazoline (I1) receptors. New Zealand White rabbits were fitted with chronic indwelling stainless-steel guide cannulas in several brain regions including the lateral ventricle, third ventricle (3V), or medullary intermediate reticular zone. Animals were allowed 5 days' recovery time prior to experiments measuring the effects of drugs on IOP via applanation pneumatonometry. Some animals were also pretreated with 400 micrograms of 6-hydroxydopamine injected into the lateral ventricle to determine the site of action of these alpha 2/I1 agonists. In initial experiments involving microinjection into the lateral ventricle, UK-14,304-18 evoked ocular hypotension that was inhibited by the alpha 2-antagonist rauwolscine but not by the I1-receptor antagonist efaroxan. Conversely, moxonidine and oxymetazoline were preferentially inhibited by efaroxan rather than by rauwolscine. Subsequently, experiments have shown that moxonidine and oxymetazoline, but not UK-14,304-18 will lower intraocular pressure when microinjected into the medullary intermediate reticular zone region and that efaroxan, but not rauwolscine, will inhibit ocular hypotension induced by moxonidine and oxymetazoline. Pretreatment with 6-hydroxydopamine (48 hours) completely eliminated the ocular hypotension induced by moxonidine. These preliminary data demonstrate that alpha 2- and I1-receptors in the brain mediate ocular hypotension induced by UK-14,304-18 and moxonidine/oxymetazoline, respectively. Moreover, the medullary intermediate reticular zone area of the brain stem is the probable presynaptic site mediating ocular hypotension induced by moxonidine and oxymetazoline.

The sympathetic nervous system modulates perception and reflex responses to gut distention in humans

BACKGROUND/AIMS

Intestinal distention induces perception and gut reflexes via sympathetic and vagal pathways, but the modulatory mechanisms of such responses remain obscure. The aim of this study was to determine the effects of sympathetic nervous activity on sympathetic and vagal reflexes as well as on intestinal and somatic perception.

METHODS

In 9 healthy volunteers, proximal duodenal distentions were produced in 4-mL increments and hand transcutaneous electrical nerve stimulation was produced in 3-mA increments. Increasing stimuli of 1-minute duration were randomly performed at 10-minute intervals both with and without sympathetic activation (induced by means of lower body negative pressure). Intestinal and somatic perception was scored by specific questionnaires; vagal enterogastric and sympathetic intestinointestinal relaxatory reflexes were simultaneously measured by gastric and distal duodenal barostats.

RESULTS

Sympathetic activation significantly heightened perception of intestinal distention without modifying perception of somatic stimuli (perception scores increased by 41% and -2%, respectively). The reflex responses to duodenal distention significantly increased during sympathetic activation both in the stomach and in the intestine (relaxation increased by 91% and 69%, respectively; P < 0.05 for both).

CONCLUSIONS

Activation of the sympathetic nervous system selectively increases visceral but not somatic sensitivity and enhances both vagally and sympathetically driven reflexes in the gut.