THE EFFECTS OF ACTIVE AND PASSIVE HYPERVENTILATION ON CEREBRAL BLOOD FLOW, CEREBRAL OXYGEN CONSUMPTION, CARDIAC OUTPUT, AND BLOOD PRESSURE OF NORMAL YOUNG MEN

Changes in human cerebral blood flow due to step changes in PAO2 and PACO2

The effect of moderate hypoxia on cerebral blood flow (CBF) in man has not been well described, and little is known about the interaction of changes in arterial PO2 and PCO2 as regards CBF. Using a non-invasive doppler ultrasound method we have measured the instantaneous mean blood velocity (which is proportional to CBF as long as the cross-section of the vessel is constant) in the carotid artery in four healthy unanaesthetized subjects. We found in all subjects that a reduction in alveolar PO2 from about 13 to about 8.7 kPa with maintained constant alveolar PCO2 (PA, CO2) caused CBF to increase gradually over 10 min (half-time about 4 min) to about 125% of control. The CBF decreased quickly (half-time about 45 s) towards control when alveolar PO2 was reset to 13 kPa. As measured 5 min after a step-change in PA, O2, the change in CBF was independent of PA, CO2 within the range 3.3-6.7 kPa. An increase in PA, O2 to about 33 kPa reduced CBF only if PA, CO2 was in the hypercapnic range. Unexpectedly we found that the CBF response showed 'adaptation' during both maintained increase and decrease in PA, CO2. The CBF started to return towards control level within 10 min after induction of hypo- or hypercapnia. We conclude that also moderate hypoxia causes increased CBF in unanaesthetized man within a wide range of PA, CO2.

Brain luxury perfusion during cardiopulmonary bypass in humans. A study of the cerebral blood flow response to changes in CO2, O2, and blood pressure

CBF and related parameters were studied in 68 patients before, during, and following cardiopulmonary bypass. CBF was measured using the intraarterial 133Xe injection method. The extracorporeal circuit was nonpulsatile with a bubble oxygenator administering 3-5% CO2 in the main group of hypercapnic patients (n = 59) and no CO2 in a second group of hypocapnic patients. In the hypercapnic patients, marked changes in CBF occurred during bypass. Evidence was found of a brain luxury perfusion that could not be related to the effect of CO2 per se. Mean CBF was 29 ml/100 g/min just before bypass, 49 ml/100 g/min at steady-state hypothermia (27 degrees C), reached a maximum of 73 ml/100 g/min during the rewarming phase (32 degrees C), fell to 56 ml/100 g/min at steady-state normothermic bypass (37 degrees C), and was 48 ml/100 g/min shortly after bypass was stopped. Addition of CO2 evoked systemic vasodilation with low blood pressure and a rebound hyperemia. The hypocapnic group responded more physiologically to the induced changes in hematocrit (Htc) and temperature, CBF being 25, 23, 25, 34, and 35 ml/100 g/min, respectively, during the five corresponding periods. Carbon dioxide was an important regulator of CBF during all phases of cardiac surgery, the responsiveness of CBF being approximately 4% for each 1-mm Hg change of PaCO2. The level of MABP was important for the CO2 response. At low blood pressure states, the CBF responsiveness to changes in PaCO2 was almost abolished. An optimal level of PaCO2 during hypothermic bypass of approximately 25 mm Hg (at actual temperature) is recommended. A normal autoregulatory response of CBF to changes in blood pressure was found during and following bypass. The lower limit of autoregulation was at pressure levels of approximately 50-60 mm Hg. CBF autoregulation was almost abolished at PaCO2 levels of greater than 50 mm Hg. The degree of hemodilution neither affected the CO2 response nor impaired CBF autoregulation, although, as would be expected, it influenced CBF: In 33 women CBF was 55 ml/100 g/min at an Htc of 24%, as compared with 42 ml/100 g/min in 35 men (Htc = 28%). High PaO2 was a vasoconstrictor, the autoregulatory plateau being narrowed. The lower limit of autoregulation was shifted to a higher pressure when PaO2 was low.

Effect in cat of locus coeruleus lesions on the response of cerebral blood flow and cardiac output to altered paCO2

In pentobarbital-anesthetized cats, over arterial paCO2 values of 20-60 mm Hg, cerebral blood flow (CBF, Xenon) and cardiac output (CO, thermal dilution) show positively inflicted curves with slopes significantly greater than zero. To examine the role of the locus coeruleus (LC) in these responses, bilateral stereotactic thermo-coagulation lesions of the LC were made. The effect of lesions confirmed to involve the LC bilaterally (n = 10), were compared with the effects of misdirected lesions placed in the cerebellum and lateral to the LC (n = 10) and sham lesions (n = 10). Ten days after the lesioning procedure, the animals were re-anesthetized with pentobarbital and paCO2 response curves were determined for CBF and CO prior to and following intravenous administration of propranolol (1 mg/kg, i.v.). The results obtained with the sham-operated animals and the animals with lesions outside of the LC were indistinguishable. Bilateral LC lesions had no significant effect on normocapnic CBF as compared to control animals. They did, however, significantly reduce the slope of the CBF paCO2 response curve. Propranolol produced a significant reduction in CBF in lesioned and non-lesioned animals measured at all levels of pCO2 and did not alter the slope of the pCO2 response curve for any group as compared to predrug values. Bilateral lesions of the LC did not significantly alter either normocapnic CO or the slope of the CO-paCO2 relationship, but did reduce the elevation in mean arterial blood pressure otherwise observed during hypercarbia. Measurement of norepinephrine levels in cortex indicate a close correlation between the ability of the lesion to reduce norepinephrine content and produce the observed physiological effects. The results of these experiments suggest that the hypercapnic response of CBF, but not CO to arterial paCO2 is modulated by systems which traverse the dorsal brainstem. The role of the locus coeruleus-catecholamine cell bodies in this effect, however, must be considered speculative until further transmitter-selective interventions are carried out.

EEG and spectral analysis in acute hyperventilation

Acute hypocapnia decreases CBF, increases hemoglobin affinity for oxygen and causes cerebral tissue hypoxia. This tissue hypoxia is reversed with inhalation of 100% O2 in dogs. EEG slowing produced by hyperventilation is considered a manifestation of cerebral hypoxia due to decreased CBF and is thought to be reversed with hyperoxia. This study evaluated the effects of 3 gas mixtures (16% O2, 21% O2, 100% O2) on posterior frequencies of the resting and hyperventilatory EEG in normal subjects aged 23-37. Hypocapnia was maintained to an end-tidal pCO2 of 21 mm Hg for 3 min. Respiratory measures, heart rate, saO2, minute ventilation and side effects were recorded. EEG was analyzed by visual inspection and by spectral analysis. Spectral analysis evaluated total amplitude, percentile frequencies, and peak frequencies. There were significant changes from eucapnia to hypocapnia for the group in all physiologic parameters, total amplitude by spectral analysis, and posterior frequencies by visual analysis. There were no significant differences among the gases. We conclude that the EEG changes of hyperventilation are independent of the concentration of inspired oxygen over the range studied in our subjects. Symptoms of hyperventilation are likewise independent of the inspired oxygen concentration for the range studied.

Ventilation and cardiac output during the onset of exercise, and during voluntary hyperventilation, in humans

Three normal subjects performed rest--exercise transitions on a cycle ergometer, from rest to unloaded pedalling (0 W), 50, 100 and 150 W. Each experiment was performed in triplicate, with randomized work load order, in two sessions. Ventilation was obtained breath-to-breath by integration of a pneumotachygraph signal, and cardiac output beat-to-beat by a new development of the Doppler technique. Results were bin-averaged in 4 s bins over the first 20 s, and compared to resting values. Both ventilation and cardiac output increased significantly in the first 2 s. This initial rise in ventilation was due entirely to an increase in rate, the subsequent rise mainly to increase in tidal volume. Cardiac output increased predominantly through change in rate with smaller increases in stroke volume. A striking feature was a tendency for ventilation and cardiac output responses to be biphasic with an initial rise followed by a slight fall at the 14 s mark, and a subsequent rise, at all work loads. Overall correlation between ventilation and cardiac output was therefore high (r = 0.92). Six normal subjects hyperventilated for 45 s voluntarily, (a) at rate 24/min and normal tidal volume; (b) at normal rate and tidal volume of 1.5 l; (c) at rate 24/min and tidal volume of 1.5 l. Cardiac output, averaged over 10-45 s, rose by 0.4, 0.5, and 1.0 l min-1 respectively, with falls in end-tidal PCO2 of 4, 6, and 8 mmHg. Six normal subjects hyperventilated for 60 s with rate 24/min and tidal volume of 1.4 l, and end-tidal PCO2 maintained at 38 +/-2 mm Hg. Cardiac output, averaged from 10-60 s, rose by 1.0 l min-1. With increased rate and tidal volume, whether isocapnic or hypocapnic, cardiac output responses showed an overshoot with a peak value at about 30 s. The hypothesis of 'cardiodynamic hyperpnoea' considers a possible effect of increasing cardiac output on ventilation. The effects of ventilation on cardiac output must also be considered. We propose an extended hypothesis involving stable positive feed-back.

Efficacy and neurologic outcome of profound hypocapneic alkalosis for the treatment of persistent pulmonary hypertension in infancy

Twenty-three newborn infants with severe bilateral pulmonary disease and persistent pulmonary hypertension received mechanical ventilation to pH greater than 7.55 and PaCO2 less than 25 torr. Response, as defined by attainment of a PaO2 greater than 100 torr, occurred in 87% of patients. Analysis of sequential arterial pH determinations revealed a linear increase in the number of infants responding as arterial pH increased. However, individual patients varied greatly in the optimal pH necessary to correct hypoxemia (range pH 7.50 to 7.75). Sixteen patients who had received mechanical hyperventilation were observed for 11.1 +/- 2.3 months. Virtually all had normal growth and development on follow-up physical and neurologic examinations, often despite profound or prolonged alkalosis and hypocarbia. In 11 infants at a corrected gestational age of 1 year, Bayley Scales of Infant Development revealed normal mental developmental indices (mean 106.2 +/- 15.4) and normal, but significantly lower, psychomotor developmental indices (93.2 +/- 11.7) (P less than 0.005). Although response and short-term outcome of neonatal hyperventilation appear favorable, this technique should be reserved for critically ill infants, because its long-term effects on the central nervous system are unknown.

Dependency of blood flow velocity in the middle cerebral artery on end-tidal carbon dioxide partial pressure--a transcranial ultrasound Doppler study

The end-tidal carbon dioxide partial pressure (PCO2) response curves for the flow velocity in the middle cerebral artery were studied in 31 normal subjects with transcranial Doppler techniques. An exponential curve with an exponent of 0.034 mm Hg-1 was found to be a good fit to the recorded data. By means of this relationship, recordings of flow velocity in cerebral arteries can be normalized to a standard value of PCO2. Physiological aspects of cerebrovascular reactivity to PCO2 and the clinical implications of the PCO2 response curve are discussed. The normal material provides a reference for assessing pathological responses.

Measurement of carotid blood flow in man and its clinical application

With the use of a new ultrasonic volume flow meter (VFM), over 8000 measurements of common carotid blood flow were made in 120 normal control subjects and 550 patients with various neurological disease. The accuracy of the flow meter in measuring blood flow on an experimental model ranged from 93 to 97%. In normal subjects, common carotid blood flow varies with age. It increased from newborn to age 20 and gradually decreased thereafter. In normal healthy subjects, the flow varies within +/- 6.7% (2SD) at one sitting (intrasession) and +/- 21.2% (2SD) from week to week (intersession study). Carotid blood flow varies linearly with PaCO2 and increased markedly in response to endotracheal intubation. In healthy adults, the flow ratio between the two common carotid arteries is 1.07 +/- 0.052. This ratio increases in patients with transient ischemic attacks to 1.28 +/- 0.23 (p less than 0.05) and in patients with intracranial space occupying lesions to 1.46 +/- 0.39, (p less than 0.01). In 26 consecutive cases of carotid endarterectomies, the preoperative common carotid blood volume flow was 5.1 +/- 1.0 cc/sec. All cases preoperatively had at least 30% stenosis and ranged from 30 to 100% stenosis. The carotid blood volume was significantly increased post-operatively (p less than 0.001). The overall accuracy in detecting carotid and cerebral arterial disease is 89% with sensitivity of 96% and the specificity of 71%. Our clinical experience indicates that this device is not only a valuable noninvasive diagnostic tool for evaluation of carotid disease but also appears to be useful in assessing cerebral blood flow.

The young-adult and normally aged brain. Its blood flow and oxidative metabolism. A review--part I

Blood flow and oxidative metabolism of the mature and healthy young-adult human brain account for about 20% of the cardiac output and about 20 and 25% of the requirements of oxygen and glucose, respectively, for the whole body. Normal cerebral aging is associated with only smaller reductions in the cerebral metabolic rates of oxygen and glucose while cerebral blood flow would seem to be unchanged. The age-dependent reduction in oxidative brain metabolism may be related to a decline in glycolytic flux due to a diminution of enzyme activities also involving acetylcholine synthesis. This metabolic reduction with age may be tentatively accounted for by a physiologically occurring loss of neurons, dendrites and dendritic spines in distinct brain areas. The mechanisms of autoregulation of cerebral blood flow, of CO2 reactivity of the brain vessels, of arterial hypoxemia on cerebral blood flow and their effects on oxidative and energy metabolism are well documented in young-adult brain. There is, however, no or only minimal information on the responsiveness of the normally aged brain to changes of these important biological parameters controlling and influencing brain blood flow and metabolism.

Metabolic alterations in a noncachectic animal tumor system

The increased energy expended by the host to synthesize substrate, which is utilized by the tumor, is a potential cause of cancer cachexia. In vivo glucose and alanine kinetics were examined by tracer methodology in a sarcoma-bearing rat model. The effects of 3-mercaptopicolinic acid, a potent inhibitor of gluconeogenesis, was also examined on this model. Both tumor-bearing (TB) and nontumor bearing (NTB) animals were gaining weight prior to study and the tumors were relatively small. The TB animals had significantly lower plasma glucose and higher blood lactic acid levels compared with NTB animals. After inhibition of gluconeogenesis, the plasma glucose decreased and the blood lactate increased significantly more in TB than NTB animals. The glucose turnover rate was significantly greater in TB compared with NTB animals, as was the rate of glucose recycling and the rate of gluconeogenesis (alanine leads to glucose), both energy demanding processes. These results suggest that the tumor-bearing animal, even prior to significant cachexia, has an excess demand for energy, the provision of which may be a significant factor in malignant cachexia.

Changes in cerebral blood flow during hyperventilation and CO2-breathing measured transcutaneously in humans by a bidirectional, pulsed, ultrasound Doppler blood velocitymeter

We have used a bidirectional pulsed ultrasound doppler system which measures the instantaneous mean velocity across the lumen of a blood vessel in order to determine the relationship between alveolar PCO2 (PACO2) and blood flow in the four arteries supplying the brain in humans. Both high and low PACO2-values were explored. Six subjects, 3 males and 3 females (22-40 years) were studied by use of this non-invasive technique. To increase the PACO2 the subjects were breathing 4, 6 and 8% CO2 in air. PACO2 was reduced by voluntary hyperventilation down to a chosen end-expiratory PCO2 value of about 2.2 kPa. We found a linear relationship between arterial blood flow expressed as a percentage of control level and PACO2 in the range from 3.3 to 7.3 kPa. At the very lowest PACO2 values a levelling off of the response, with flow values of 40 to 45%, was observed. The CO2-reactivities in the 6 persons varied between 28.1 and 30.0%/kPa. The time course and the magnitude of the flow response were similar in all four arteries.

Positron imaging of cerebral blood flow during continuous inhalation of C15O2

This investigation tests the hypothesis that the normal cerebral image obtained non-invasively during continuous inhalation of C15O2 is related to cerebral blood flow. Trace amounts of CO2 labeled with the positron-emitting radionuclide 15O were administered to 4 normal subjects at normo- and hypocapnia and to 2 of these subjects at hypercapnia. Hypocapnia typically caused a marked decrease in cerebral 15O activity, and hypercapnia a small increase in activity. The relative difference in the change in count rate in response to hypo- and hypercapnia is what one would expect if the activity represented bloow flow, according to a mathematical model which assumes the 15O label enters the brain as water of perfusion. The findings in this study suggest that the normal cerebral image obtained during continuous inhalation of C15O2 is related to cerebral blood flow, but in a non-linear fashion, and that the technique would be more sensitive to ischemic events than to hyperemic phenomena.

Sympathetic modulation of hypercapnic cerebral vasodilation in dogs

We measured cerebral blood flow using both the radioactive microsphere technique and the cerebral venous outflow technique in dogs anesthetized with chloralase. The effect of sympathetic stimulation on cerebral blood flow was observed during both normocapnia and prolonged hypercapnia using both blood flow techniques. The increase in blood flow with hypercapnia was the same with both methods. During hypercapnia the venous outflow method showed a 38% decrease and microspheres an 18% decrease in cerebral blood flow with sympathetic stimulation. At normal CO2, stimulation caused a decrease in cerebral venous flow: no change was observed with the microsphere method. Analysis of the blood flow patterns to extracerebral tissues and evaluation of extracerebral arterial reference samples failed to prove the existence of axial streaming and subsequent skimming of microspheres within the cephalic circulation. It is concluded that direct electrical stimulation of the sympathetic innervation of the cerebral vessels is capable of reducing cerebral blood flow even during a profound hypercapnic vasodilation.

Circulatory effect of respiratory maneuvers

The circulatory effects of three kinds of respiratory maneuvers--maximum breathing, voluntary hyperventilation, and the Valsalva maneuver--on cerebral blood flow, brachial blood flow, heart rate, and systolic blood pressure were investigated by means of the on-line Doppler ultrasonic technique in 20 men. Arterial gas contents (PO2, PCO2, pH) were also examined. Cerebral blood flow was increased or showed the biphasic response (increase in the former and decrease in the latter part of the maneuver) with maximum breathing. Cerebral blood flow was decreased with voluntary hyperventilation. The cerebral blood flow was maintained at a same level during the maneuver or tended to return to the control level. Cerebral blood flow was decreased in the Valsalva maneuver. There was a transient but conspicious increase of the cerebral blood flow immediately after the maneuver.

Cyanide intoxication in Macaca mulatta. Physiological and neuropathological aspects

Sodium cyanide was infused intravenously in 11 lightly anaesthetised and spontaneously breathing M. mulatta. In most, the EEG, ECG, respiratory rate, blood pressure, cerebral venous sinus pressure, end-tidal pCO2 and body temperature were recorded. Blood gases, pH, lactate and pyruvate were estimated in arterial and venous sinus blood samples. There was an initial hyperventilation with tetany in all animals. A rapid rate of cyanide infusion led to apnoea. An isoelectric or near-isoelectric EEG was usually precipitated by bradycardia often with additional hypotension. Neither epileptic seizures nor their EEG concomitants were seen at any stage. Three animals died of early heart failure. Brain damage was seen in 4 animals surviving up to 98 hr. White matter was involved in all. Ischaemic neuronal alterations, restricted to the striatum of one animal, were attributed to major circulatory complications. It was concluded that under these experimental conditions there is no evidence for hypoxic neuronal damage of purely histotoxic type.

Cerebrovascular CO2 reactivity in normotensive and hypertensive man

Cerebrovascular reactivity to CO2 inhalation and voluntary hyperventilation was studied in seven normotensive subjects and nine hypertensive patients without clinical or angiographical signs of arteriosclerosis. Cerebral blood flow (CBF) was measured by the intracarotid 133Xe clearance method and calculated as the initial slope index. Three to five CBF measurements were made in each patient in the PaCO2 range of 20 to 55 mm Hg. No difference was observed in reactivity between hypertensive and normotensive patients, either during CO2 inhalation or during hyperventilation. The shape of the CBF:PaCO2 curve suggested a decrease in reactivity below a PaCO2 of 30 to 35 mm Hg in both groups. Above a PaCO2 of 35 mm Hg, exponential regression analysis yielded a mean reactivity of 6 +/- 2%, whereas below a PaCO2 of 30 mm Hg it was about 2%. The rise in CBF during CO2 inhalation was not influenced by the intravenous infusion of a small dose of trimethaphan which blocked the concomitant rise in blood pressure.

Concepts and clinical utility of the measurement of cerebral blood flow

Within the past several decades, techniques that accurately measure regional cerebral blood flow have been developed. At the present time, the inert gas washout technique using an intraarterial injection of 133Xe with the Anger scintillation camera or multiple probes as the external detector is the most established of these methods. While quantitative measures of cerebral blood flow have been important in elucidating the physiology of cerebral hemodynamics, the techniques are too invasive for routinely screening patients with cerebrovascular disease. As a result, less invasive methods have been sought for diagnostic screening. Because it requires only an intravenous injection of 99mTc-pertechnetate, the radionuclide cerebral angiogram has achieved some popularity as a semiquantitative measure of cerebral hemodynamics, particularly when coupled with static brain scintigraphy. This review examines our current understanding of cerebral hemodynamics and the advantages and limitations of techniques used to measure cerebral blood flow.

Effects of hyperventilation, CO2, and CSF pressure on internal carotid blood flow in the baboon

The combined effect upon cerebral blood flow (CBF) of an elevation of cerebrospinal fluid pressure (CSFP) and changes in respiratory CO2 was studied in nine baboons under chloralose anesthesia. The animals were mildly hyperventilated and provided with increasing amounts of CO2 in O2-air. Arterial CO2 tensions (PaCO2) increased from 17 to 58 mm Hg. Internal carotid blood flow (ICBF) was measured at normal CSFP and at hydrostatically maintained 50 mm Hg CSFP. It was found that: 1) end-tidal CO2 may be used as a substitute for arterial PaCO2 determinations; 2) this elevation of CSFP has little effect on ICBF during hypercapnia and normocapnia; however, 3) during hypocapnia the ICBF is reduced an additional 20% when CSFP is elevated; that is, ICBF is reduced 50% from normal when end-tidal CO2 is reduced to 2% at this elevated level of CSFP. Caution should be exercised during hyperventilation therapy particularly if the elevated CSFP or intracranial pressure (ICP) is not reduced to approach normal levels; in these conditions, the combination of decreasing PaCO2 and elevated ICP may reduce CBF below critical levels and thus lead to cerebral hypoxia.

Hemorrhagic shock with fixed hypotension and with spontaneous recovery of blood pressure. A comparison of two shock models

In 26 dogs anesthetized with a barbiturate peripheral blood flow, O2 consumption and acid-base balance have been studied in two kinds of hemorrhagic shock: 1. Hemorrhagic shock with fixed hypotension (hypotensive shock, n = 12) 2. Hemorrhagic shock with spontaneously recovering arterial blood pressure (normotensive shock, n = 14). In both groups the same amount of blood is withdrawn and stored in a reservoir (31-32 ml/kg) to reduce arterial pressure to 40 mm Hg. In hypotensive shock there is a continuous outflow of blood into the reservoir in order to maintain an arterial pressure of 40 mm Hg. After 1 1/2 hours this shift of blood reverses itself spontaneously. In normotensive shock the arterial pressure is allowed to increase after the initial withdrawal of blood. 1 1/2 hours later it reaches a peak of 93 mm Hg after which it starts declining again. The duration of oligemia which the animals control themselves is nearly identical in both groups (4 hours). Both kinds of hemorrhagic shock have a mortality rate of 80%. The survival time is shorter (p less than 0.01) in hypotensive (3 hours) than in normotensive shock (7 1/2 hours). In both kinds of shock heart rate increases to more than 200 beats/min. However, in hypotensive shock it decreases in the late stage of hypovolemia, whereas the increase is continuous in normotensive shock. Cardiac output is significantly higher in the normotensive animals nearly throughout the entire hypovolemic phase although the initial decrease is the same in both groups (71%). Also a greater increase in total peripheral resistance occurs in these animals. The increased cardiac output and total peripheral resistance. A "centralization" of the circulation is also observed in this kind of shock as is made evident by the changes in the relationship between cardiac output and carotid blood flow. Hyperventilation occurs in both kinds of shock. In hypotensive shock respiratory rate decreases at the end of the oligemic phase possibly due to a smaller cerebral blood flow.

Regional cerebral blood flow response to hypocapnia in the contralateral hemisphere of patients with acute cerebral infarction

The rCBF response to hypocapnia induced by active short-term hyperventilation was determined in the contralateral hemispheres of ten patients with acute unilateral cerebral infarction. Overall rCBF reduction occurred in only two patients. Regional or widespread abnormal responses to Paco2 reduction manifested as either no change or a paradoxical increase in the rCBF were observed in eight patients. The hemispheric mean rCBF reduction following hypocapnia was diminished as compared with control subjects. Our findings suggest that an impairment of the chemical control of rCBF may occur in the non-infarcted hemisphere during the early period following the onset of cerebral infarction. The pathophysiological mechanisms which may underlie this abnormal rCBF reactivity to Paco2 reduction are considered.

Effect of physical exercise on internal carotid artery blood flow after arterial reconstruction

The effect of physical exercise on internal carotid artery (ICA) blood flow in conscious man was studied with the aid of electromagnetic flowmetry. A flow probe was implanted on the ICA in 25 patients after reconstruction of the artery. ICA mean blood flow and brachial artery mean blood pressure were continuously monitored in supine (25 patients) and sitting (24 patients) position at rest, during 5-6 minutes exercise on a bicycle ergometer and at rest after exercise. Arterial carbon dioxide tension (PaCO2) was studied in 6/25 work tests in supine and 7/24 in sitting position. Cardiac output was measured at rest and during exercise in 10/25 patients in supine and 8/24 patients in sitting position. In the supine group, ICA flow increased significantly within 1 minute and reached a maximal flow 15% above control flow within 2 minutes after the onset of exercise. The ICA flow then gradually declined, but remained almost significantly elevated, 7.5% above control, on termination of exercise. At rest, after exercise, the ICA flow decreased almost significantly to a level of 5% below the control flow within 5 minutes. There was a significant PaCO2 increase of 2.6 mmHg during exercise and a highly significant increase (72%) in cardiac output during exercise. The ICA flow at rest, before exercise, was about 15% lower in the sitting group than in the supine group. It increased in average 11.5% with 2 minutes of exercise and then gradually diminished. At rest, after exercise, ICA flow decreased further to a level of 8% below control flow within 5 minutes. PaCO2 increased significantly in average 1.6 mmHg during exercise. Cardiac output increased highly significantly (85%) during exercise. The ICA flow changes obtained during exercise in the present study indicate the presence of a regulatory mechanism counteracting the increasing perfusion pressure, but it is unable to compensate the decreased perfusion pressure when the body position was altered from supine to sitting. The cerebral vascular bed in the present patient material seems to operate above and below the lower limit of its pressure range for an adequate autoregulation.

The effects of changes in PaCO2 on cerebral blood volume, blood flow, and vascular mean transit time

The relationships between cerebral blood volume (CBV), cerebral blood flow (CBF), and the cerebral vascular mean transit time (t v ) during acute changes in the Pa CO 2 over a range of 15 to 76 torr were investigated in vivo in rhesus monkeys by serially determining the mean transit time of a vascular tracer, 15 O-labeled carboxyhemoglobin, and the mean transit time of a diffusible tracer, 15 O-labeled water. Over this range of Pa CO 2 , a significant linear relationship of CBV = 0.041 Pa CO 2 + 2.0 was found. For each one torr change in Pa CO 2 , there is a change in CBV of 0.041 ml/100 gm of perfused tissue. At a normocarbic value of Pa CO 2 (37 torr), an average value of 3.5 ml/100 gm was found. A nonlinear relationship of CBV and CBF was found. This relationship is expressed in the equation, CBV = 0.80 CBF 0.38 . A significant linear relationship was found between CBF and Pa CO 2 . This was described by the equation, CBF = 1.8 Pa CO 2 - 16.75. For each one torr change in the PaCO 2 , there is a 1.8 ml/100 gm per minute change in the CBF. At a normocarbic value of Pa CO 2 (37 torr), an average value of CBF of 50 ml/100 gm per minute was found. The relationship of CBV and t v was nonlinear and was expressed in the equation, t C15O = 41 CBF -0.62 .

The relationship of regional cerebrovascular CO2 reactivity to blood pressure and regional resting flow

Cerebrovascular CO 2 reactivity (the change in cerebral blood flow per mm Hg change in Pa co co 2 ) is shown to be directly related to resting flow and inversely related to blood pressure for regional as well as for mean CBF data. Both regional and mean CO 2 reactivity therefore are proportional to the ratio resting flow/blood pressure. This ratio is the reciprocal of resistance and may be called conductance . When regional CO 2 reactivity for 428 cerebral areas is plotted against an approximation of regional conductance, the data describe positive linear relationships similar to those found when mean CO 2 , reactivity is plotted against mean conductance. These relationships can be demonstrated whether CO 2 reactivity is calculated with specific or percent change in flow, the data describe positive linear lerationships similar to those found when mean CO 2 basal tone of the cerebrovascular bed. The way in which CO 2 reactivity relates to conductance, therefore, may be a more reliable index of the integrity of the cerebrovascular CO 2 response than the CBF change per se. Analysis of CO 2 reactivity as a function of conductance may facilitate the interpretation of mean and regional CO 2 reactivity and may provide a more meaningful basis for comparison of the CO 2 response between individuals.

Adrenergic blockade of hypocapnic cerebral arterial constriction

Hypocapnic constriction of the basilar and vertebral arteries was produced and pharmacologically modified (by intrathecal administration) in nine Rhesus monkeys. The arteries were then removed and studied with a catecholamine fluorescent technique. Alterations in P CO CO 2 were associated with significant changes in the caliber of large arteries. Mere depletion of the periarterial norepinephrine stores did not prevent hypocapnic vasoconstriction. The latter was reversed, however, by alpha adrenergic blockade (phenoxybenzamine). The alpha adrenergic receptor appears to be a mediating site for hypocapnic constriction of the intracranial vessels. We have proposed that the alpha receptor may be H + sensitive so that changes in pH alter the responsiveness of the adrenergic receptor to transmitter substances.

Effect of PaCO2 on hyperemia and ischemia in experimental cerebral infarction

To assess the effects of Pa CO CO 2 on cerebral ischemia and reactive hyperemia, the right middle cerebral artery was occluded in 18 cats. Four to six hours later, Pa CO 2 was adjusted by mechanical ventilation, with or without CO 2 , to less than 20 torr in four cats, 31 to 38 torr in six, and 46 to 68 torr in eight. Regional cerebral blood flow (CBF) then was measured at multiple sites in each hemisphere by autoradiography. In regions of brain tissue outside the distribution of the occluded middle cerebral artery, log 10 CBF correlated positively with Pa CO CO 2 . In ischemic regions, CBF was higher in normocapnic cats. Reactive hyperemia occurred in two cats of the hypocapnic group, in four cats of the normocapnic group, but in only one hypercapnic cat (Pa CO CO 2 = 46 torr). Hyperemia also was found outside potentially ischemic regions in five cats. Multiple hyperemic foci developed in six cats. Neither hypocapnia nor hypercapnia was associated with a smaller size or higher CBF of regions of cerebral ischemia produced by occlusion of a middle cerebral artery, although hypercapnia inhibited the development of hyperemia.

Protective effects of acetazolamide and hyperbaric oxygenation on experimentally induced syncope

The protective effects of acetazolamide and hyperbaric oxygenation on experimentally induced syncope were evaluated in seven healthy male subjects. Syncope was induced by vigorous hyperventilation and Valsalva maneuver. Each subject performed these procedures three times in each of the following conditions: (1) breathing room air at normal atmospheric pressure, (2) breathing 100% oxygen at 2.36 atmospheric pressure, (3) breathing 9% oxygen at 2.36 atmospheres and (4) after intravenous injection of 500 mg of acetazolamide while breathing 100% oxygen at 2.36 atmospheres. With comparable changes of arterial pCO 2 and blood pressure during the hyperventilation-Valsalva maneuver, syncope occurred in 19 of 21 (91%) hyperventilation-Valsalva maneuvers performed at ambient environment, in 18 of 21 (86%) when subject was breathing 9% oxygen at 2.36 atmospheres, in 14 of 21 (67%) when 2.36 atmospheres of 100% oxygen was used, and in only 7 of 21 (33%) when acetazolamide was used in conjunction with hyperbaric oxygen. Syncope was completely prevented by hyperbaric oxygenation in one subject and by the combination of acetazolamide and hyperbaric oxygen in four subjects. These studies demonstrate that cerebral vasodilation induced by acetazolamide combined with increased oxygen delivery to the brain resulting from hyperbaric oxygenation may preserve cerebral function during the period of hypotension and hypocapnia produced by hyperventilation and Valsalva maneuver.