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Panerai RB, Brassard P, Burma JS, Castro P, Claassen JA, van Lieshout JJ, Liu J, Lucas SJ, Minhas JS, Mitsis GD, Nogueira RC, Ogoh S, Payne SJ, Rickards CA, Robertson AD, Rodrigues GD, Smirl JD, Simpson DM. Transfer function analysis of dynamic cerebral autoregulation: A CARNet white paper 2022 update. J Cereb Blood Flow Metab 2023; 43:3-25. [PMID: 35962478 PMCID: PMC9875346 DOI: 10.1177/0271678x221119760] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Cerebral autoregulation (CA) refers to the control of cerebral tissue blood flow (CBF) in response to changes in perfusion pressure. Due to the challenges of measuring intracranial pressure, CA is often described as the relationship between mean arterial pressure (MAP) and CBF. Dynamic CA (dCA) can be assessed using multiple techniques, with transfer function analysis (TFA) being the most common. A 2016 white paper by members of an international Cerebrovascular Research Network (CARNet) that is focused on CA strove to improve TFA standardization by way of introducing data acquisition, analysis, and reporting guidelines. Since then, additional evidence has allowed for the improvement and refinement of the original recommendations, as well as for the inclusion of new guidelines to reflect recent advances in the field. This second edition of the white paper contains more robust, evidence-based recommendations, which have been expanded to address current streams of inquiry, including optimizing MAP variability, acquiring CBF estimates from alternative methods, estimating alternative dCA metrics, and incorporating dCA quantification into clinical trials. Implementation of these new and revised recommendations is important to improve the reliability and reproducibility of dCA studies, and to facilitate inter-institutional collaboration and the comparison of results between studies.
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Affiliation(s)
- Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester and NIHR Biomedical Research Centre, Leicester, UK
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, and Research Center of the Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Joel S Burma
- Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Pedro Castro
- Department of Neurology, Centro Hospitalar Universitário de São João, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jurgen Ahr Claassen
- Department of Geriatric Medicine and Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Johannes J van Lieshout
- Department of Internal Medicine, Amsterdam, UMC, The Netherlands and Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, University of Nottingham Medical School, Queen's Medical Centre, UK
| | - Jia Liu
- Institute of Advanced Computing and Digital Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen University Town, Shenzhen, China
| | - Samuel Je Lucas
- School of Sport, Exercise and Rehabilitation Sciences and Centre for Human Brain Health, University of Birmingham, Birmingham, UK
| | - Jatinder S Minhas
- Department of Cardiovascular Sciences, University of Leicester and NIHR Biomedical Research Centre, Leicester, UK
| | - Georgios D Mitsis
- Department of Bioengineering, McGill University, Montreal, Québec, QC, Canada
| | - Ricardo C Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | - Shigehiko Ogoh
- Department of Biomedical Engineering, Toyo University, Kawagoe-Shi, Saitama, Japan
| | - Stephen J Payne
- Institute of Applied Mechanics, National Taiwan University, Taipei
| | - Caroline A Rickards
- Department of Physiology & Anatomy, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Andrew D Robertson
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Gabriel D Rodrigues
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Jonathan D Smirl
- Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - David M Simpson
- Institute of Sound and Vibration Research, University of Southampton, Southampton, UK
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Barnes SC, Panerai RB, Beishon L, Hanby M, Robinson TG, Haunton VJ. Cerebrovascular responses to somatomotor stimulation in Parkinson's disease: A multivariate analysis. J Cereb Blood Flow Metab 2022; 42:1547-1558. [PMID: 35287495 PMCID: PMC9274867 DOI: 10.1177/0271678x211065204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Parkinson's disease (PD) is a common neurodegenerative disorder, yet little is known about cerebral haemodynamics in this patient population. Previous studies assessing dynamic cerebral autoregulation (dCA), neurovascular coupling (NVC) and vasomotor reactivity (VMR) have yielded conflicting findings. By using multi-variate modelling, we aimed to determine whether cerebral blood flow (CBF) regulation is impaired in PD patients.55 healthy controls (HC) and 49 PD patients were recruited. PD subjects underwent a second recording following a period of abstinence from their anti-Parkinsonian medication. Continuous bilateral transcranial Doppler in the middle cerebral arteries, beat-to-beat mean arterial blood pressure (MAP; Finapres), heart rate (HR; electrocardiogram), and end-tidal CO2 (EtCO2; capnography) were measured. After a 5-min baseline period, a passive motor paradigm comprising 60 s of elbow flexion was performed. Multi-variate modelling quantified the contributions of MAP, ETCO2 and neural stimulation to changes in CBF velocity (CBFV). dCA, VMR and NVC were quantified to assess the integrity of CBF regulation.Neural stimulation was the dominant input. dCA, NVC and VMR were all found to be impaired in the PD population relative to HC (p < 0.01, p = 0.04, p < 0.01, respectively). Our data suggest PD may be associated with depressed CBF regulation. This warrants further assessment using different neural stimuli.
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Affiliation(s)
- Sam C Barnes
- Department of Cardiovascular Sciences, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester, UK
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester, UK.,NIHR Leicester Biomedical Research Centre, BHF Cardiovascular Research Centre, Glenfield Hospital, Leicester, UK
| | - Lucy Beishon
- Department of Cardiovascular Sciences, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester, UK.,NIHR Leicester Biomedical Research Centre, BHF Cardiovascular Research Centre, Glenfield Hospital, Leicester, UK
| | - Martha Hanby
- Department of Cardiovascular Sciences, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester, UK.,NIHR Leicester Biomedical Research Centre, BHF Cardiovascular Research Centre, Glenfield Hospital, Leicester, UK
| | - Victoria J Haunton
- Department of Cardiovascular Sciences, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester, UK.,NIHR Leicester Biomedical Research Centre, BHF Cardiovascular Research Centre, Glenfield Hospital, Leicester, UK
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Yin K, Zhou C, Zhu Y, Yin W, Yin L, Liu B, Ren H, Xu Z, Yang X. REM sleep behavioral disorder may be an independent risk factor for orthostatic hypotension in Parkinson's disease. Aging Clin Exp Res 2022; 34:159-166. [PMID: 34021898 DOI: 10.1007/s40520-021-01887-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the association between clinically possible rapid eye movement (REM) sleep behavioral disorder (pRBD) and orthostatic hypotension (OH) in PD patients, as well as to explore the mechanisms underlying the association. METHODS PD patients (n = 116) were assigned to a group with OH (PD-OH) or without OH (PD-NOH). General demographic and clinical data were collected. A series of scales were used to assess the clinical symptoms in the two groups. RESULTS A total of 27 patients (23.3%) had OH. The PD-OH group showed significantly higher H-Y staging score and significantly higher frequencies of pRBD, anxiety, depression, and cognitive impairment than the PD-NOH group. Binary logistic regression analysis identified the following factors as independently associated with PD-OH: H-Y staging [odds ratio (OR) 2.565, 95% confidence interval (CI) 1.160-5.673; P = 0.020], RBD (OR 7.680, 95% CI 1.944-30.346; P = 0.004), UPDRS II (OR 1.021, 95% CI 0.980-1.063; P = 0.020), depression (OR 7.601, 95% CI 1.492-38.718; P = 0.015), and cognitive impairment (OR 0.824, 95% CI 0.696-0.976; P = 0.025). CONCLUSIONS Our results suggest that pRBD is an independent risk factor for OH in patients with PD. We speculate that there may be a close relationship between RBD and OH, which requires attention. Early diagnosis of RBD may help predict the appearance of OH in PD patients.
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van Campen C(LM, Rowe PC, Visser FC. Cerebral Blood Flow Is Reduced in Severe Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Patients During Mild Orthostatic Stress Testing: An Exploratory Study at 20 Degrees of Head-Up Tilt Testing. Healthcare (Basel) 2020; 8:healthcare8020169. [PMID: 32545797 PMCID: PMC7349207 DOI: 10.3390/healthcare8020169] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/01/2020] [Accepted: 06/10/2020] [Indexed: 12/14/2022] Open
Abstract
Introduction: In a study of 429 adults with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), we demonstrated that 86% had symptoms of orthostatic intolerance in daily life. Using extracranial Doppler measurements of the internal carotid and vertebral arteries during a 30-min head-up tilt to 70 degrees, 90% had an abnormal reduction in cerebral blood flow (CBF). A standard head-up tilt test of this duration might not be tolerated by the most severely affected bed-ridden ME/CFS patients. This study examined whether a shorter 15-min test at a lower 20 degree tilt angle would be sufficient to provoke reductions in cerebral blood flow in severe ME/CFS patients. Methods and results: Nineteen severe ME/CFS patients with orthostatic intolerance complaints in daily life were studied: 18 females. The mean (SD) age was 35(14) years, body surface area (BSA) was 1.8(0.2) m2 and BMI was 24.0(5.4) kg/m2. The median disease duration was 14 (IQR 5–18) years. Heart rate increased, and stroke volume index and end-tidal CO2 decreased significantly during the test (p ranging from <0.001 to <0.0001). The cardiac index decreased by 26(7)%: p < 0.0001. CBF decreased from 617(72) to 452(63) mL/min, a 27(5)% decline. All 19 severely affected ME/CFS patients met the criteria for an abnormal CBF reduction. Conclusions: Using a less demanding 20 degree tilt test for 15 min in severe ME/CFS patients resulted in a mean CBF decline of 27%. This is comparable to the mean 26% decline previously noted in less severely affected patients studied during a 30-min 70 degree head-up tilt. These observations have implications for the evaluation and treatment of severely affected individuals with ME/CFS.
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Affiliation(s)
| | - Peter C. Rowe
- Department of Paediatrics, John Hopkins University School of Medicine, Baltimore, MD 21205, USA;
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van Campen C(LM, Verheugt FW, Rowe PC, Visser FC. Cerebral blood flow is reduced in ME/CFS during head-up tilt testing even in the absence of hypotension or tachycardia: A quantitative, controlled study using Doppler echography. Clin Neurophysiol Pract 2020; 5:50-58. [PMID: 32140630 PMCID: PMC7044650 DOI: 10.1016/j.cnp.2020.01.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/05/2019] [Accepted: 01/02/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The underlying hypothesis in orthostatic intolerance (OI) syndromes is that symptoms are associated with cerebral blood flow (CBF) reduction. Indirect CBF measurements (transcranial Doppler flow velocities), provide inconsistent support of this hypothesis. The aim of the study was to measure CBF during a 30 min head-up tilt test (HUT), using Doppler flow imaging of carotid and vertebral arteries, in individuals with chronic fatigue syndrome/myalgic encephalomyelitis (ME/CFS), a condition with a high prevalence of OI. METHODS 429 ME/CFS patients were studied: 247 had a normal heart rate (HR) and blood pressure (BP) response to HUT, 62 had delayed orthostatic hypotension (dOH), and 120 had postural orthostatic tachycardia syndrome (POTS). We also studied 44 healthy controls (HC). CBF measurements were made at mid-tilt and end-tilt. Before mid-tilt, we administered a verbal questionnaire to ascertain for 15 OI symptoms. RESULTS End-tilt CBF reduction was 7% in HC versus 26% in the overall ME/CFS group, 24% in patients with a normal HR/BP response, 28% in those with dOH, and 29% in POTS patients (all P < .0005). Using a lower limit of normal of 2SD of CBF reduction in HC (13% reduction), 82% of patients with normal HR/BP response, 98% with dOH and 100% with POTS showed an abnormal CBF reduction. There was a linear correlation of summed OI symptoms with the degree of CBF reduction at mid-tilt (P < .0005). CONCLUSIONS During HUT, extracranial Doppler measurements demonstrate that CBF is reduced in ME/CFS patients with POTS, dOH, and even in those without HR/BP abnormalities. SIGNIFICANCE This study shows that orthostatic intolerance symptoms are related to CBF reduction, and that the majority of ME/CFS patients (90%) show an abnormal cerebral flow reduction during orthostatic stress testing. This may have implications for the diagnosis and treatment of ME/CFS patients.
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Affiliation(s)
| | - Freek W.A. Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Oosterpark 9, 1091 AC Amsterdam, The Netherlands
| | - Peter C. Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frans C. Visser
- Stichting CardioZorg, Planetenweg 5, 2132 HN Hoofddorp, The Netherlands
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Shi J, Yan M, Dong Y, Zheng X, Zhang Q, An H. Multiple Kernel Learning Based Classification of Parkinson's Disease With Multi-Modal Transcranial Sonography. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2019; 2018:61-64. [PMID: 30440341 DOI: 10.1109/embc.2018.8512194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Parkinson's Disease (PD) is the most common motor neurodegenerative disease in elderly population. Transcranial sonography (TCS) has become a popular imaging tool for diagnosis of PD in clinical practice. Moreover, several pioneering work have developed the computer-aided diagnosis (CAD) for PD with the transcranial B-mode sonography (TBS). It is worth noting that TCS not only has the TBS modality, but also can image the blood flow of major cerebral arteries, which is named transcranial Doppler sonography (TDS). TDS also has been applied to evaluate PD patients with orthostatic hypotension. However, the TDS-based CAD for PD has not been investigated. Since TBS and TDS provide the complementary structural and functional information about brain, it is feasible to develop a multi-modal TCS-based CAD for PD by combining both TBS and TDS. Therefore, in this work, we propose a multiple kernel learning (MKL) based CAD for PD with multi-modal TCS imaging. Particularly, the statistical and texture features are extracted from the midbrain region from TBS images, and the features about blood flow are calculated from the spectrum curves in TDS. The multi-modal features are then fed to a MKL classifier for classification of PD. The experimental results show that the multi-modal TCS-based method outperforms both the single-modal TBS- and TDS-based algorithm, which suggests the feasibility and effectiveness of combining TBS and TDS for diagnosis of PD.
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Robertson AD, Udow SJ, Espay AJ, Merola A, Camicioli R, Lang AE, Masellis M. Orthostatic hypotension and dementia incidence: links and implications. Neuropsychiatr Dis Treat 2019; 15:2181-2194. [PMID: 31447560 PMCID: PMC6683958 DOI: 10.2147/ndt.s182123] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/09/2019] [Indexed: 12/14/2022] Open
Abstract
Orthostatic hypotension (OH) is a common condition, particularly in patients with α-synucleinopathies such as Parkinson's disease, and has a significant impact on activities of daily living and quality of life. Recent data suggest an association with cognitive impairment. Herein, we review the evidence that OH increases the odds of incident mild cognitive impairment and dementia. Potential mechanisms underlying the putative relationship are discussed, including cerebral hypoperfusion, supine hypertension, white matter hyperintensities, and neurodegeneration. Finally, we highlight the challenges with respect to treatment and the negative impact on the quality of life and long-term prognosis presented by the coexistence of OH and dementia. Large population-based studies have reported that OH is associated with about a 20% increased risk of dementia in the general population, while smaller cohort studies suggest an even greater effect in patients with α-synucleinopathies (3- to 7-fold higher than controls). Ultimately, OH exposure is difficult to quantify, predominantly limited to pressure regulation during a one-time orthostatic challenge, and the causative association with dementia may turn out to be bidirectional, especially in α-synucleinopathies. Early diagnosis and treatment of OH may improve long-term prognosis.
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Affiliation(s)
- Andrew D Robertson
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, ON, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Sean J Udow
- Division of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Alberto J Espay
- Department of Neurology, James and Joan Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, OH, USA
| | - Aristide Merola
- Department of Neurology, James and Joan Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, OH, USA
| | - Richard Camicioli
- Department of Medicine (Neurology), University of Alberta, Edmonton, AB, Canada
| | - Anthony E Lang
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University Health Network, Toronto, ON, Canada.,Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Mario Masellis
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada.,Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Cognitive and Movement Disorders Clinic, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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8
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Obara T, Nagai K, Shibata S, Hirasawa A, Koshiba H, Hasegawa H, Ebihara T, Kozaki K. Relationship between the severity of cerebral white matter hyperintensities and sympathetic nervous activity in older adults. Geriatr Gerontol Int 2017; 18:569-575. [PMID: 29193629 DOI: 10.1111/ggi.13217] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/11/2017] [Accepted: 10/09/2017] [Indexed: 11/27/2022]
Abstract
AIM White matter hyperintensities (WMH), visualized on brain magnetic resonance imaging, represent an abnormality related to the development of geriatric syndromes. Recently, it has been found that low sympathetic nervous activity might be associated with physical and cognitive dysfunction in older adults. Therefore, we investigated the relationship between the severity of cerebral WMH and sympathetic nervous activity, measured by the heart rate variability. METHODS We carried out a cross-sectional study of 39 older patients. Holter recording was carried out for 30 min. From the RR intervals on the electrocardiogram, the standard deviation of the normal-to-normal intervals, the standard deviation of all normal-to-normal intervals in all the five segments of the entire recording, low frequency (LF), high frequency (HF) and LF/HF were calculated. In regard to the WMH, periventricular hyperintensities and deep white matter hyperintensities (DWMH) were rated according to the Fazekas classification. The WMH were also rated semiquantitatively according to the methods developed by Junque (periventricular hyperintensities) and de Groot (DWMH). RESULTS The LF/HF showed significant negative correlations with the total and regional periventricular hyperintensities, as well as DWMH. Multiple regression analysis showed that the negative associations remained significant between the LF/HF and DWMH (total, temporal, occipital). Furthermore, fall risk index significantly correlated with the LF/HF, total and the occipital DWMH. CONCLUSIONS The severity of the DWMH was associated with the LF/HF and the fall risk, one of the important geriatric syndromes, suggesting that WMH, sympathetic nervous dysfunction and geriatric syndrome are interrelated to each other. Geriatr Gerontol Int 2018; 18: 569-575.
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Affiliation(s)
- Toshimasa Obara
- Department of Geriatric Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Kumiko Nagai
- Department of Geriatric Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Shigeki Shibata
- Department of Geriatric Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Ai Hirasawa
- Department of Geriatric Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Hitomi Koshiba
- Department of Geriatric Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Hiroshi Hasegawa
- Department of Geriatric Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Takae Ebihara
- Department of Geriatric Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Koichi Kozaki
- Department of Geriatric Medicine, Kyorin University School of Medicine, Tokyo, Japan
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9
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Transcranial Doppler in autonomic testing: standards and clinical applications. Clin Auton Res 2017; 28:187-202. [PMID: 28821991 DOI: 10.1007/s10286-017-0454-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/13/2017] [Indexed: 02/06/2023]
Abstract
When cerebral blood flow falls below a critical limit, syncope occurs and, if prolonged, ischemia leads to neuronal death. The cerebral circulation has its own complex finely tuned autoregulatory mechanisms to ensure blood supply to the brain can meet the high metabolic demands of the underlying neuronal tissue. This involves the interplay between myogenic and metabolic mechanisms, input from noradrenergic and cholinergic neurons, and the release of vasoactive substrates, including adenosine from astrocytes and nitric oxide from the endothelium. Transcranial Doppler (TCD) is a non-invasive technique that provides real-time measurements of cerebral blood flow velocity. TCD can be very useful in the work-up of a patient with recurrent syncope. Cerebral autoregulatory mechanisms help defend the brain against hypoperfusion when perfusion pressure falls on standing. Syncope occurs when hypotension is severe, and susceptibility increases with hyperventilation, hypocapnia, and cerebral vasoconstriction. Here we review clinical standards for the acquisition and analysis of TCD signals in the autonomic laboratory and the multiple methods available to assess cerebral autoregulation. We also describe the control of cerebral blood flow in autonomic disorders and functional syndromes.
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10
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Park J, Kim HT, Park KM, Ha SY, Kim SE, Shin KJ, Kim SE, Jang W, Kim JS, Youn J, Oh E, Park S. Orthostatic dizziness in Parkinson's disease is attributed to cerebral hypoperfusion: A transcranial doppler study. JOURNAL OF CLINICAL ULTRASOUND : JCU 2017; 45:337-342. [PMID: 28401995 DOI: 10.1002/jcu.22452] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 11/09/2016] [Accepted: 11/19/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Orthostatic hypotension (OH) is controversially regarded as the cause of orthostatic dizziness in Parkinson's disease (PD). We sought to evaluate whether cerebral autoregulation is an alternative cause for orthostatic dizziness in PD patients, using transcranial Doppler monitoring during head-up tilting. METHODS Forty-five PD patients with dizziness, 13 PD patients without dizziness, and 10 age-matched healthy controls were enrolled. Participants were divided into the following four groups: patients with dizziness and OH (group 1, n = 22), patients with dizziness but no OH (n = 23, group 2), patients without dizziness (n = 11, group 3), and age-matched healthy controls (n = 10, group 4). All participants underwent transcranial Doppler and blood pressure monitoring for 10 minutes during the head-up tilt test. Changes in the cerebral blood flow velocity (CBFV) in the middle cerebral artery and the mean blood pressure (mBP) within 3 minutes after head-up tilting were compared between groups. RESULTS Group 1 showed a significantly higher change in mBP (-16.3 ± 10.8 mmHg) than groups 2 (-2.6 ± 4.9), 3 (-2.2 ± 3.6), or 4 (1.8 ± 6.0) (p < 0.001). However, groups 3 (4.6 ± 3.0 cm/s) and 4 (-4.2 ± 2.5) showed a significantly smaller change in CBFV than groups 1 (-9.0 ± 4.2) and 2 (-8.1 ± 5.1) (p < 0.01). CONCLUSIONS Our results suggest that cerebral hypoperfusion contributes to dizziness in PD patients despite a lack of OH. Transcranial Doppler monitoring during head-up tilting may be a useful tool for evaluating dizziness in PD patients with or without OH. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:337-342, 2017.
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Affiliation(s)
- Jinse Park
- Department of Neurology, Haeundae Paik Hospital, Inje University, Busan, Republic of Korea
| | - Hee-Tae Kim
- Department of Neurology, Hanyang University College of Medicine, Hanyang University, College of Medicine, Seoul, Republic of Korea
| | - Kang Min Park
- Department of Neurology, Haeundae Paik Hospital, Inje University, Busan, Republic of Korea
| | - Sam Yeol Ha
- Department of Neurology, Haeundae Paik Hospital, Inje University, Busan, Republic of Korea
| | - Sung Eun Kim
- Department of Neurology, Haeundae Paik Hospital, Inje University, Busan, Republic of Korea
| | - Kyong Jin Shin
- Department of Neurology, Haeundae Paik Hospital, Inje University, Busan, Republic of Korea
| | - Si Eun Kim
- Department of Neurology, Haeundae Paik Hospital, Inje University, Busan, Republic of Korea
| | - Wooyoung Jang
- Department of Neurology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Ji Sun Kim
- Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Jinyoung Youn
- Department of Neurology, Samsung Medical Center, College of Medicine Sungkyunkwan University, Seoul, Republic of Korea
| | - Engsoek Oh
- Department of Neurology, Chungnam National University Hospital, College of Medicine, Daejun, Republic of Korea
| | - Suyeon Park
- Department of Biostatistics, Soonchunhyang University Hospital, Seoul, Republic of Korea
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Robertson AD, Messner MA, Shirzadi Z, Kleiner-Fisman G, Lee J, Hopyan J, Lang AE, Black SE, MacIntosh BJ, Masellis M. Orthostatic hypotension, cerebral hypoperfusion, and visuospatial deficits in Lewy body disorders. Parkinsonism Relat Disord 2016; 22:80-6. [DOI: 10.1016/j.parkreldis.2015.11.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 11/09/2015] [Accepted: 11/17/2015] [Indexed: 02/08/2023]
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12
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Indelicato E, Fanciulli A, Poewe W, Antonini A, Pontieri FE, Wenning GK. Cerebral autoregulation and white matter lesions in Parkinson's disease and multiple system atrophy. Parkinsonism Relat Disord 2015; 21:1393-7. [PMID: 26578037 DOI: 10.1016/j.parkreldis.2015.10.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 09/23/2015] [Accepted: 10/29/2015] [Indexed: 11/28/2022]
Abstract
Cerebral autoregulation is a complex homeostatic process which ensures constant brain blood supply, despite continuous blood pressure fluctuations. Recent evidence suggests that in Parkinson's disease (PD) and multiple system atrophy (MSA) this process is maintained in a broadened range of blood pressure values, consistent with an adaptive mechanism to increase tolerance to orthostatic hypotension. In PD and MSA orthostatic hypotension may be accompanied by supine hypertension which has been recently linked with cerebral white matter lesions in these conditions. We hypothesize that cerebral autoregulation adaptation to chronic orthostatic hypotension may be directly related with an increase susceptibility to hypertensive peaks. Evaluation of cerebral autoregulatory behavior may thus represent a novel approach to simultaneously target orthostatic symptoms and silent end-organ damage in alpha-synucleinopathies, with a beneficial impact on cerebrovascular and cognitive outcome.
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Affiliation(s)
- Elisabetta Indelicato
- Department of Neuroscience, Mental Health and Sensory Organs, "Sapienza" University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy; IRCCS Santa Lucia Foundation, Via Ardeatina 306, 00179 Rome, Italy.
| | - Alessandra Fanciulli
- Department of Neuroscience, Mental Health and Sensory Organs, "Sapienza" University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy; Department of Neurology, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Werner Poewe
- Department of Neurology, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Angelo Antonini
- IRCCS Ospedale San Camillo, Via Alberoni 70, 30126 Venice, Italy
| | - Francesco E Pontieri
- Department of Neuroscience, Mental Health and Sensory Organs, "Sapienza" University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy; IRCCS Santa Lucia Foundation, Via Ardeatina 306, 00179 Rome, Italy
| | - Gregor K Wenning
- Department of Neurology, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
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Abnormal Cerebrovascular Reactivity in Patients with Parkinson's Disease. PARKINSONS DISEASE 2015; 2015:523041. [PMID: 26167330 PMCID: PMC4488013 DOI: 10.1155/2015/523041] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 06/04/2015] [Accepted: 06/07/2015] [Indexed: 12/31/2022]
Abstract
Background. Orthostatic hypotension (OH) is an important nonmotor manifestation of Parkinson's disease (PD). Changes in cerebrovascular reactivity may contribute to this manifestation and can be monitored using transcranial Doppler. Objective. To identify possible changes in cerebrovascular reactivity in patients with OH. Methods. Twenty-two individuals were selected and divided into three groups: with and without OH and controls. Transcranial Doppler was used to assess basal mean blood flow velocity, postapnea mean blood flow velocity, percentage increase in mean blood flow velocity, and cerebrovascular reactivity as measured by the breath-holding index. Results. PD patients had lower values of basal velocity (p = 0.019), postapnea velocity (p = 0.0015), percentage increase in velocity (p = 0.039), and breath-holding index (p = 0.04) than the controls. Patients with OH had higher values of basal velocity (p = 0.09) and postapnea velocity (p = 0.19) but lower values of percentage increase in velocity (p = 0.22) and breath-holding index (p = 0.32) than patients without OH. Conclusions. PD patients present with abnormalities in a compensatory mechanism that regulates cerebral blood flow. OH could be an indicator of these abnormalities.
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Transfer function analysis for the assessment of cerebral autoregulation using spontaneous oscillations in blood pressure and cerebral blood flow. Med Eng Phys 2014; 36:563-75. [DOI: 10.1016/j.medengphy.2014.02.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 01/31/2014] [Accepted: 02/03/2014] [Indexed: 12/21/2022]
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Orthostatic hypotension in patients with Parkinson's disease and atypical parkinsonism. PARKINSONS DISEASE 2014; 2014:475854. [PMID: 24634790 PMCID: PMC3929346 DOI: 10.1155/2014/475854] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 12/11/2013] [Indexed: 12/23/2022]
Abstract
Orthostatic hypotension (OH) is one of the commonly occurring nonmotor symptoms in patients with idiopathic Parkinson's disease (IPD) and atypical parkinsonism (AP). We aimed to review current evidences on epidemiology, diagnosis, treatment, and prognosis of OH in patients with IPD and AP. Major electronic medical databases were assessed including PubMed/MEDLINE and Embase up to February 2013. English-written original or review articles with keywords such as "Parkinson's disease," "atypical parkinsonism," and "orthostatic hypotension" were searched for relevant evidences. We addressed different issues such as OH definition, epidemiologic characteristics, pathophysiology, testing and diagnosis, risk factors for symptomatic OH, OH as an early sign of IPD, prognosis, and treatment options of OH in parkinsonian syndromes. Symptomatic OH is present in up to 30% of IPD, 80% of multiple system atrophy (MSA), and 27% of other AP patients. OH may herald the onset of PD before cardinal motor symptoms and our review emphasises the importance of its timely diagnosis (even as one preclinical marker) and multifactorial treatment, starting with patient education and lifestyle approach. Advancing age, male sex, disease severity, and duration and subtype of motor symptoms are predisposing factors. OH increases the risk of falls, which affects the quality of life in PD patients.
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Perez-Lloret S, Rey MV, Pavy-Le Traon A, Rascol O. Orthostatic hypotension in Parkinson’s disease. Neurodegener Dis Manag 2013. [DOI: 10.2217/nmt.13.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
SUMMARY Orthostatic hypotension (OH) is a frequent non-motor symptom in Parkinson’s disease (PD), affecting between 22.9 and 38.4% of patients. In PD, OH is related to an increased risk of falls, and possibly to cognitive dysfunction and increased mortality. These data emphasize the importance of its prompt recognition and treatment. OH is related to pre- and post-ganglionic adrenergic denervation, but other factors, such as drugs, heat, meals or alcohol intake, might also induce or aggravate it. Evidence about the efficacy and safety of pharmacological or nonpharmacological strategies for OH treatment in PD is weak. Nonpharmacological measures include liberal addition of salt to the diet, exercise, compression stockings or physical maneuvers. Severe cases may be treated with midodrine or fludrocortisone. Some results suggest that droxidopa and fipamezole may be effective treatments. We finish this review article by discussing the most important unanswered questions about PD-related OH, which may be the focus of future research.
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Affiliation(s)
- Santiago Perez-Lloret
- Clinical Pharmacology & Epidemiology Laboratory, Pontifical Catholic University, Buenos Aires, Argentina
- Departments of Clinical Pharmacology & Neurosciences, & Clinical Investigation Center CIC9302, Institut National de la Santé & de la Recherche Médicale & University Hospital, University of Toulouse III, 37 Allées Jules Guesde, 31000, Toulouse, France
| | - María Verónica Rey
- Departments of Clinical Pharmacology & Neurosciences, & Clinical Investigation Center CIC9302, Institut National de la Santé & de la Recherche Médicale & University Hospital, University of Toulouse III, 37 Allées Jules Guesde, 31000, Toulouse, France
- Clinical Pharmacology & Epidemiology Laboratory, Pontifical Catholic University, Buenos Aires, Argentina
| | - Anne Pavy-Le Traon
- Departments of Clinical Pharmacology & Neurosciences, & Clinical Investigation Center CIC9302, Institut National de la Santé & de la Recherche Médicale & University Hospital, University of Toulouse III, 37 Allées Jules Guesde, 31000, Toulouse, France
| | - Olivier Rascol
- Departments of Clinical Pharmacology & Neurosciences, & Clinical Investigation Center CIC9302, Institut National de la Santé & de la Recherche Médicale & University Hospital, University of Toulouse III, 37 Allées Jules Guesde, 31000, Toulouse, France
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Rätsep T, Asser T. Subthalamic stimulation improves the cerebral hemodynamic response to the cold pressure test in patients with Parkinson's disease. JOURNAL OF CLINICAL ULTRASOUND : JCU 2012; 40:547-553. [PMID: 22941961 DOI: 10.1002/jcu.21984] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 08/06/2012] [Indexed: 06/01/2023]
Abstract
PURPOSE Disturbances of the autonomic nervous system are common in patients with Parkinson's disease (PD) but the effect of deep brain stimulation of the subthalamic nucleus on cerebrovascular reactivity is not entirely known. METHODS Seven patients in an advanced stage of the disease and seven healthy age-matched controls participated in the study, which took place after one night of drug withdrawal. Cerebral blood flow velocity was continuously monitored on both sides with transcranial Doppler ultrasound, and cerebrovascular reactivity (CR) was evaluated with the cold pressure test. The measurements were repeated and compared during the stimulation-on and -off phases. RESULTS The PD patients had significantly higher CR values in the stimulation-on than -off conditions (15.1% ± 6.9 versus 9.4% ± 6.2; p = 0.03). CR values were higher in controls than in patients in the stimulation-off condition (20.4% ± 12.5 versus 9.4% ± 6.2; p = 0.007) without a significant difference with the stimulation-on phase. CONCLUSIONS CR, evaluated by the response to the cold pressure test, is impaired in patients with advanced PD and improved by subthalamic nucleus.
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Affiliation(s)
- Tõnu Rätsep
- Department of Neurology and Neurosurgery, University of Tartu, Estonia
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Fanciulli A, Strano S, Colosimo C, Caltagirone C, Spalletta G, Pontieri FE. The potential prognostic role of cardiovascular autonomic failure in α-synucleinopathies. Eur J Neurol 2012; 20:231-5. [PMID: 22834919 DOI: 10.1111/j.1468-1331.2012.03819.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Accepted: 06/12/2012] [Indexed: 11/29/2022]
Abstract
Cardiovascular autonomic failure is the second most common dysautonomic feature of α-synucleinopathies and has significant impact on daily activities and quality of life. Here we provide a systematic review of cardiovascular autonomic failure in α-synucleinopathies, emphasizing its impact on cognitive functions and disease outcomes. Articles spanning the period between January 1985 and April 2012 were identified from the PubMed database using a keyword-based search. Epidemiological studies highlight the negative prognostic effect of cardiovascular autonomic failure on cardiovascular and cerebrovascular outcomes and overall mortality in all α-synucleinopathies. Altered cerebral perfusion, vascular pressure stress, and related disruption of the blood-brain barrier may also contribute to the white matter hyperintensities and cognitive dysfunction frequently found in patients affected by neurocardiovascular instability. These findings support the hypothesis that cardiovascular autonomic failure may play a negative prognostic role in α-synucleinopathies and suggest that precocious screening and therapeutic management of cardiovascular autonomic failure may positively impact disease course.
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Affiliation(s)
- A Fanciulli
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
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