The central connections of the vagus nerve in the ferret

Vagus nerve stimulation for primary headache disorders: An anatomical review to explain a clinical phenomenon

BACKGROUND

Non-invasive stimulation of the vagus nerve has been proposed as a new neuromodulation therapy to treat primary headache disorders, as the vagus nerve is hypothesized to modulate the headache pain pathways in the brain. Vagus nerve stimulation can be performed by placing an electrode on the ear to stimulate the tragus nerve, which contains about 1% of the vagus fibers. Non-invasive vagus nerve stimulation (nVNS) conventionally refers to stimulation of the cervical branch of the vagus nerve, which is made up entirely of vagal nerve fibers. While used interchangeably, most of the research to date has been performed with nVNS or an implanted vagus nerve stimulation device. However, the exact mechanism of action of nVNS remains hypothetical and no clear overview of the effectiveness of nVNS in primary headache disorders is available.

METHODS

In the present study, the clinical trials that investigated the effectiveness, tolerability and safety of nVNS in primary headache disorders were systematically reviewed. The second part of this study reviewed the central connections of the vagus nerve. Papers on the clinical use of nVNS and the anatomical investigations were included based on predefined criteria, evaluated, and results were reported in a narrative way.

RESULTS

The first part of this review shows that nVNS in primary headache disorders is moderately effective, safe and well-tolerated. Regarding the anatomical review, it was reported that fibers from the vagus nerve intertwine with fibers from the trigeminal, facial, glossopharyngeal and hypoglossal nerves, mostly in the trigeminal spinal tract. Second, the four nuclei of the vagus nerve (nuclei of the solitary tract, nucleus ambiguus, spinal nucleus of the trigeminal nerve and dorsal motor nucleus (DMX)) show extensive interconnections. Third, the efferents from the vagal nuclei that receive sensory and visceral input (i.e. nuclei of the solitary tract and spinal nucleus of the trigeminal nerve) mainly course towards the main parts of the neural pain matrix directly or indirectly via other vagal nuclei.

CONCLUSION

The moderate effectiveness of nVNS in treating primary headache disorders can possibly be linked to the connections between the trigeminal and vagal systems as described in animals.

Integration of vestibular and emetic gastrointestinal signals that produce nausea and vomiting: potential contributions to motion sickness

Vomiting and nausea can be elicited by a variety of stimuli, although there is considerable evidence that the same brainstem areas mediate these responses despite the triggering mechanism. A variety of experimental approaches showed that nucleus tractus solitarius, the dorsolateral reticular formation of the caudal medulla (lateral tegmental field), and the parabrachial nucleus play key roles in integrating signals that trigger nausea and vomiting. These brainstem areas presumably coordinate the contractions of the diaphragm and abdominal muscles that result in vomiting. However, it is unclear whether these regions also mediate the autonomic responses that precede and accompany vomiting, including alterations in gastrointestinal activity, sweating, and changes in blood flow to the skin. Recent studies showed that delivery of an emetic compound to the gastrointestinal system affects the processing of vestibular inputs in the lateral tegmental field and parabrachial nucleus, potentially altering susceptibility for vestibular-elicited vomiting. Findings from these studies suggested that multiple emetic inputs converge on the same brainstem neurons, such that delivery of one emetic stimulus affects the processing of another emetic signal. Despite the advances in understanding the neurobiology of nausea and vomiting, much is left to be learned. Additional neurophysiologic studies, particularly those conducted in conscious animals, will be crucial to discern the integrative processes in the brain stem that result in emesis.

Action of anti-tussive drugs on the emetic reflex of Suncus murinus (house musk shrew)

The cough and emetic reflexes involve a synchronized firing of motor neurones involved in respiratory control. Tachykinin NK1 receptor antagonists and 5-HT1A receptor agonists are examples of centrally acting drugs that reduce cough and emesis. In the present studies, therefore, we examined the possibility that other classes of drugs known to reducing cough have anti-emetic properties to prevent emesis induced by diverse challenges. We examined the potential of codeine (1-10 mg/kg), baclofen (1-10 mg/kg), scopolamine (0.3-10 mg/kg), diphenhydramine (1-10 mg/kg), imperialine (1-30 mg/kg) and verticine (0.3-3 mg/kg) to inhibit emesis induced by nicotine (5 mg/kg, s.c.), copper sulphate (120 mg/kg, intragastric), and provocative motion (4 cm horizontal displacement, delivered at 1 Hz) in Suncus murinus (house musk shrew). Only codeine had broad inhibitory properties (P<0.05) to antagonize emesis induced by all challenges with ID50 values ranging from 1.2 to 2.3 mg/kg. Baclofen antagonized emesis induced by nicotine (maximum reduction was 44.9%, P<0.05) and motion (maximum reduction was 97.3%, P<0.01), but potentiated copper sulphate-induced emesis (maximum potentiation was 73.0%, P<0.05). Scopolamine antagonized copper sulphate-induced emesis (maximum reduction was 61.2%, P<0.05) and imperialine antagonized nicotine-induced emesis (maximum reduction was 30.2%, P<0.01), but verticine potentiated motion-induced emesis (maximum potentiation was 60.0%, P<0.05). Diphenhydramine did not significantly reduce emesis induced by any of the challenges (P>0.05). In conclusion, codeine has broad inhibitory anti-emetic actions but a known ability to reduce coughing does not necessarily predict broad inhibitory anti-emetic properties.

Ghrelin concentrations and cardiac vagal tone are decreased after pharmacologic and cognitive-behavioral treatment in patients with bulimia nervosa

Patients with bulimia nervosa (BN) have bulimic and depressive symptoms, which have been associated with abnormalities in the neuroendocrine and vagal systems. Subjects included twenty-four female drug-free outpatients with BN that were selected from patients seeking treatment for eating behavior in our hospital along with twenty-five age-matched healthy females who served as controls. We investigated ghrelin and leptin levels, cardiac vagal tone and sympathovagal balance, frequency of sets of binge-eating and vomiting episodes per week and the Profile of Mood States (POMS) depression scale in BN before and after a 16-week administration of the serotonin selective reuptake inhibitor (SSRI) paroxetine combined with cognitive-behavioral therapy. Compared to controls, the BN group had higher ghrelin levels and resting cardiac vagal tone, and lower leptin levels and resting cardiac sympathovagal balance before treatment, although there was a significant difference between the two groups for the body mass index (BMI). The elevated ghrelin levels (301.7 +/- 18.9 pmol/l, mean +/- SEM vs. 202.8 +/- 15.6 pmol/l, P < 0.01), cardiac vagal tone (2246.4 +/- 335.5 ms(2) vs. 1128.5 +/- 193.3 ms(2), P < 0.01), frequency of sets of binge-eating and purging episodes and T scores for the POMS depression scale were all significantly decreased after treatment despite similar BMI, percent body fat and leptin levels. In close association with cardiac vagal function and ghrelin recoveries, abnormal eating behavior and depressive symptoms improved, indicating the usefulness of these indexes in the assessment of clinical condition and therapeutic efficacy in BN.

Roles of substance P and NK(1) receptor in the brainstem in the development of emesis

The emetic response is primarily a protective reflex occurring in a wide variety of vertebrates in response to the ingestion of toxic compounds. The role of the nuclei in the brainstem, including the area postrema, nucleus tractus solitarius, the dorsal motor nucleus of the vagus, and the central pattern generator for vomiting, as well as the involvement of the abdominal visceral innervation relevant to the emetic reflex, have all been discussed by many researchers. The introduction of serotonin 5-HT(3)-receptor antagonists into clinical practice allowed for a dramatic improvement in the management of vomiting. However, vomiting still remains a significant problem. The mechanism of the emetic response is even more complicated than was first thought. This review attempts to bring together some of the evidence suggesting the roles of substance P and its receptor, neurokinin NK(1) receptor, in the brainstem nuclei in the development of emesis. Accordingly, NK(1)-receptor antagonists might represent novel drugs for the management of major types of emesis.

Localization of phosphodiesterase-4 isoforms in the medulla and nodose ganglion of the squirrel monkey

Pre-clinical and clinical studies are currently underway to evaluate the potential of phosphodiesterase-4 (PDE4) inhibitors for the treatment of chronic obstructive pulmonary disease and other inflammatory conditions of the airways. The most common side effect associated with this class of compounds is emesis. The squirrel monkey provides a model for evaluating the efficacy of PDE4 inhibitors and their emetic potential. The distribution of three PDE4 isoforms (A, C and D) has been investigated in the squirrel monkey medulla and nodose ganglion to determine which isoform(s) could be responsible for the emetic adverse effects. The distribution of PDE4 isoforms was delineated using immunohistochemistry with antibodies specific for PDE4A, PDE4C and PDE4D and by in situ hybridization with isoform-selective riboprobes. PDE4A was present in the medulla where expression was mostly restricted to glial cells and the vasculature. PDE4C was not detected in either the medulla or nodose ganglion. Finally, the PDE4D isoform was localized to neurons in the nodose ganglion and found through many structures of medulla including the area postrema, neurons of the nucleus tractus solitarius and locus coeruleus. These data are consistent with a role for PDE4D in the emetic response.

Cannabinoids inhibit emesis through CB1 receptors in the brainstem of the ferret

BACKGROUND & AIMS

Marijuana and other cannabinoids are effective anti-emetics. Despite ongoing controversy over their usage, the receptor distribution and the site of the anti-emetic action of these compounds are not known. Our aim was to investigate whether the cannabinoid 1 receptor (CB1r) and endocannabinoids play a role in the anti-emetic action of cannabinoids.

METHODS

Ferrets were given an emetic stimulus and the number of episodes of retching and vomiting were observed after administration of CB1r agonists and a CB1r antagonist. CB1r and fatty acid amide hydrolase (FAAH), which degrades endocannabinoids, were localized by immunohistochemistry.

RESULTS

CB1r and FAAH were localized in the dorsal vagal complex, consisting of the area postrema, nucleus of the solitary tract, and the dorsal motor nucleus of the vagus in the brainstem. CB1r was found in the myenteric plexus of the stomach and duodenum. Activation of CB1r by the agonists (delta)(9)-tetrahydrocannabinol, WIN 55,212-2, and methanandamide inhibited emesis and their action was reversed by a selective CB1r antagonist, which alone had no effect, but potentiated vomiting in response to an emetic stimulus.

CONCLUSIONS

CB1r mediates the anti-emetic action of cannabinoids in the dorsal vagal complex. Endocannabinoids are a novel neuroregulatory system involved in the control of emesis.

Imiquimod-elicited emesis is mediated by the area postrema, but not by direct neuronal activation

The immunomodulator, imiquimod, has been shown to have antiviral and antitumor properties in animal models. It also has been reported to alter cytokine levels in both animals and humans. However, because imiquimod appeared to be emetic, studies were conducted to determine the degree of sensitivity, and the pathways involved. Subcutaneous administration of > or = 10 mg/kg imiquimod to ferrets elicited emesis with latencies as short as 2'; 12 and 15 mg/kg were optimal doses. Emetic responsiveness was eliminated by complete ablation of the area postrema, but was unaffected by bilateral supradiaphragmatic section of the vagus nerve. This indicates that the emesis is produced by an activation of the chemoreceptor trigger zone B the area postrema. Ferret brain stem slices (450 microm) were preincubated in oxygenated Krebs-Ringer and then mounted in a submerged slice recording chamber. Extracellular recordings of spontaneous and ionophoretically evoked activity of area postrema neurons were obtained for up to 8 h, while the effect of bath-applied imiquimod was determined. Under control conditions, neurons showed a low frequency spontaneous discharge. Introduction of imiquimod (concentration range, 1 x 10(-7) to 5 x 10(-8)M) had no effect on neuronal firing. With ionophoresis of glutamate from an independent micropipette, a brief excitatory response was obtained. We conclude that imiquimod does not directly excite area postrema neurons. It is likely that imiquimod causes synthesis and release of some unknown emetic substance(s), very possibly cytokines.

Electrolytic lesions of the pedunculopontine nucleus disrupt concurrent learned aversion induced by NaCl

Bilateral electrolytic lesions in the pedunculopontine nucleus (PPN) impair acquisition of short-term, or concurrent, Taste Aversion Learning (TAL) in rats. This type of TAL is characterized by the daily presentation of two different flavor stimuli at the same time, one associated with simultaneous intragastric administration of an aversive product (hypertonic NaCl) and the other with physiological saline. Sham-lesioned control animals learn this taste discrimination task, but both lesioned animals and control animals learn a long-term, or delayed, TAL task in which each gustatory stimulus is presented individually every other day and the intragastric products, LiCl (0.15 M) and physiological saline, are administered after a 15-min delay. These results are analyzed in the context of the cerebellar circuits involved in learning and in relation to the two TAL modalities described above.

The role of tachykinin NK-1 receptors in the area postrema of ferrets in emesis

The role of tachykinin NK-1 receptors in the area postrema (AP) in emesis was examined in ferrets. Strong c-fos-like immunoreactivity was observed in the AP and nucleus tractus solitalius (NTS) in cisplatin (10 mg/kg, i.p.)-treated animals, but not in control animals. The number of the central emetogen morphine-induced vomits and retches was remarkably reduced (95%) and that of the peripheral emetogen copper sulphate-induced vomits was significantly (54%) reduced by AP lesion. Pretreatment with the tachykinin NK-1 receptor antagonists HSP-117 (1.0 microg) and CP-99,994 (7.5 microg) into the AP decreased the numbers of vomits and retches induced by morphine and copper sulphate. These results suggest that NK-1 receptors in the AP are involved in the mechanism of emesis induced by morphine and copper sulphate.

Brainstem origin of the efferent components of the cervical vagus nerve in the house musk shrew, Suncus murinus

The brainstem origin of the efferent neurons of the vagus nerve in the house musk shrew, an animal species which has been recently used in researches on emesis, was studied using the retrograde tracing method. The vagus nerve was exposed and cut at the mid-cervical level below the nodose ganglion. Horseradish peroxidase was applied to the proximal end of the cut nerve. The brainstem was sectioned and processed histochemically with the tetramethylbenzidine method. The horseradish peroxidase injection into the vagus nerve resulted in heavy retrograde labelling of neurons in the ipsilateral dorsal motor nucleus of the vagus nerve and ambigual nuclear complex. Labelled neurons in the dorsal motor nucleus of the vagus nerve, constituting approximately 80% of the total labelled neurons, formed a longitudinal column whose length varied from 3.4 to 3.8 mm. Half of labelled neurons in this nucleus were found at the level between the area postrema and 0.6 mm rostral to it. The ambigual nuclear complex was made up of two major longitudinal divisions; the dorsal division corresponded to the ambiguus nucleus and the ventral division was identified as the external formation of the ambiguus nucleus. Our results suggest that in the Suncus murinus the neuroanatomical feature of the dorsal motor nucleus of the vagus nerve is similar to those of other mammals, but ambigual nuclear complex must be somewhat different between mammals.

Fluoxetine normalizes increased cardiac vagal tone in bulimia nervosa

Patients with bulimia nervosa have been reported to respond to treatment with the serotonin uptake inhibitor fluoxetine. In a preliminary study, which had a small sample size, women with bulimia nervosa were reported to have elevated cardiac vagal tone. We investigated cardiac vagal tone in women with bulimia nervosa before and after treatment with fluoxetine. At baseline, resting cardiac vagal tone, deduced from the respiratory component of heart rate variability, was quantified in 41 healthy volunteer women and in 25 women with bulimia nervosa. The bulimic women received in a parallel-group design, double blind, either placebo or fluoxetine 60 mg/24 hr for 8 weeks. All patients participated in behavioral therapy. Resting cardiac vagal tone was measured again at the end of the treatment. Women with bulimia nervosa had higher cardiac vagal tone than age-matched healthy volunteer women. Placebo had no effect on cardiac vagal tone. Fluoxetine reduced cardiac vagal tone among the women with bulimia nervosa to a level similar to the healthy volunteer women. Women with bulimia nervosa have elevated resting cardiac vagal tone. Fluoxetine normalized the elevated resting cardiac vagal tone among the women with bulimia nervosa. At both the central and peripheral levels, vagal neurons are endowed with serotonin-3 receptors. In vitro, fluoxetine desensitizes or blocks serotonin-3 receptors. A controlled trial of serotonin-3 receptor blockers is warranted in bulimia nervosa.

Neurochemical modulation of cardiovascular control in the nucleus tractus solitarius

The central control of cardiovascular function has been keenly studied for a number of decades. Of particular interest are the homeostatic control mechanisms, such as the baroreceptor heart-rate reflex, the chemoreceptor reflex, the Bezold-Jarisch reflex and the Breuer-Hering reflex. These neurally-mediated reflexes share a common termination point for their respective centrally-projecting sensory afferents, namely the nucleus tractus solitarius (NTS). Thus, the NTS clearly plays a critical role in the integration of peripherally initiated sensory information regarding the status of blood pressure, heart rate and respiratory function. Many endogenous neurochemicals, from simple amino acids through biogenic amines to complex peptides have the ability to modulate blood pressure and heart rate at the level of the NTS. This review will attempt to collate the current knowledge regarding the roles of neuromodulators in the NTS, the receptor types involved in mediating observed responses and the degree of importance of such neurochemicals in the tonic regulation of the cardiovascular system. The neural pathway that controls the baroreceptor heart-rate reflex will be the main focus of attention, including discussion of the identity of the neurotransmitter(s) thought to act at baroafferent terminals within the NTS. In addition, this review will provide a timely update on the use of recently developed molecular biological techniques that have been employed in the study of the NTS, complementing more classical research.