Comparison between pial and intraparenchymal vascular responses to cervical sympathetic stimulation in cats. Part 1. Under normal resting conditions

Effect of Percutaneous Inferior Sympathetic Ganglion Block on Medium-Sized Intracranial Artery Diameters on Cerebral Angiography

BACKGROUND

Some data suggest a vasodilatory effect of sympathetic blockade in patients with aneurysmal subarachnoid hemorrhage, but the effect on medium-sized intracranial arteries remains unclear. We report the results of serial cerebral angiography to study the cerebral vasodilatory effects of percutaneous inferior sympathetic ganglion block in 2 patients.

METHODS

Serial ipsilateral intracranial angiograms were obtained before and after percutaneous inferior sympathetic ganglion block and were imported to a DICOM reader, Horos Open-Source Medical Image Viewer (version 3.3.6). The percent change of arterial diameter was calculated in the intracranial internal carotid artery (ICA), middle carotid artery (MCA), and anterior cerebral artery (ACA). We assessed the interobserver reliability using the Bland-Altman method.

RESULTS

In Patient 1, there was an average increase in diameter of intracranial ICA and MCA at 1 minute, 5 minutes, and 10 minutes, with a relative decrease in the diameter of the ACA. In Patient 2, there was an average relative increase in diameter of intracranial ICA and MCA at 1 minute, 5 minutes, 10 minutes, 20 minutes, and 30 minutes, with a relative increase in diameter at 5 minutes, 10 minutes, and 30 minutes in the ACA. The Bland-Altman coefficient of variation was -5.35 (range -0.44 to 0.28) with all the data points within the 98% upper and lower limits of acceptance.

CONCLUSIONS

We observed vasodilation in medium-sized intracranial arteries ipsilateral to the percutaneous inferior sympathetic ganglion block as early as 1 minute post treatment and persisting for at least until 30 minutes post blockade.

The locus coeruleus-norepinephrine network optimizes coupling of cerebral blood volume with oxygen demand

Given the brain's uniquely high cell density and tissue oxygen levels bordering on hypoxia, the ability to rapidly and precisely match blood flow to constantly changing patterns in neural activity is an essential feature of cerebrovascular regulation. Locus coeruleus-norepinephrine (LC-NE) projections innervate the cerebral vasculature and can mediate vasoconstriction. However, function of the LC-mediated constriction in blood-flow regulation has never been addressed. Here, using intrinsic optical imaging coupled with an anesthesia regimen that only minimally interferes with LC activity, we show that NE enhances spatial and temporal aspects of functional hyperemia in the mouse somatosensory cortex. Increasing NE levels in the cortex using an α(2)-adrenergic receptor antagonist paradoxically reduces the extent of functional hyperemia while enhancing the surround blood-flow reduction. However, the NE-mediated vasoconstriction optimizes spatial and temporal focusing of the hyperemic response resulting in a sixfold decrease in the disparity between blood volume and oxygen demand. In addition, NE-mediated vasoconstriction accelerated redistribution to subsequently active regions, enhancing temporal synchronization of blood delivery. These observations show an important role for NE in optimizing neurovascular coupling. As LC neuron loss is prominent in Alzheimer and Parkinson diseases, the diminished ability to couple blood volume to oxygen demand may contribute to their pathogenesis.

Effects of stellate ganglion block on cerebral haemodynamics as assessed by transcranial Doppler ultrasonography

BACKGROUND

Stellate ganglion block (SGB) causes vasodilatation in the skin of the head and neck because of regional sympathetic block. Its effects on cerebral haemodynamics, in health or in disease, are not clear. We evaluated the effects of SGB on ipsilateral middle cerebral artery flow velocity (MCAFV), estimated cerebral perfusion pressure (eCPP), zero flow pressure (ZFP), carbon dioxide reactivity (CO2R) and cerebral autoregulation using transcranial Doppler ultrasonography (TCD).

METHODS

Twenty male patients, with pre-existing brachial plexus injury, and undergoing SGB for the treatment of complex regional pain syndrome of the upper limb, were studied. For SGB, 10 ml of plain lidocaine 2% was used and the onset of block was confirmed by presence of ipsilateral Horner's syndrome. The MCAFV, eCPP, ZFP, CO2R, and cerebral autoregulation were assessed before and after SGB using established TCD methods. The changes in these variables were analysed using Wilcoxon's signed rank test.

RESULTS

The block caused a significant decrease in MCAFV from median (inter-quartile range) value of 61 (53, 67) to 55 (46, 60) cm s(-1), a significant increase in eCPP from 59 (51, 67) to 70 (60, 78) mm Hg, and a significant decrease in ZFP from 32 (26, 39) to 25 (16, 30) mm Hg. There were no significant changes in CO2R or cerebral autoregulation.

CONCLUSION

The increase in eCPP, decrease in ZFP, and no changes in CO2R or cerebral autoregulation suggest that the SGB decreases cerebral vascular tone without affecting the capacity of the vessels to autoregulate. These effects may be of therapeutic advantage in relieving cerebral vasospasm in certain clinical settings.

Differential effects of increasing doses of alpha-trinositol on cerebral blood flow autoregulation

The effect of neuropeptide Y inhibition with alpha-trinositol on the cerebral blood flow autoregulation was studied in Wistar Kyoto rats. alpha-Trinositol was tested in two doses: one dose (5 mg kg-1 hr-1) selectively affecting neuropeptide Y and one higher dose (50 mg kg-1 hr-1) affecting both neuropeptide Y and the adrenergic response. The cerebral blood flow was measured with the intracarotid 133xenon injection method in halothane nitrous oxide-anaesthetized animals. Blood pressure was raised by norepinephrine infusion and lowered by controlled haemorrhage in separate groups of rats. In addition we examined the effect of alpha-trinositol on neuropeptide Y-induced contraction of cerebral vessels in vitro. The in vitro study demonstrated inhibition of neuropeptide Y-induced contraction with a alpha-trinositol dose selective of neuropeptide Y. The in vivo study demonstrated that cerebral blood flow autoregulation was preserved after both doses of alpha-trinositol. alpha-Trinositol in the low neuropeptide Y-selective dose (5 mg kg-1 hr-1) did not affect the blood pressure limits of cerebral blood flow autoregulation, but the higher dose (50 mg kg-1 hr-1) of alpha-trinositol shifted the upper blood pressure limit of cerebral blood flow autoregulation towards lower blood pressures, an effect probably due to inhibition of both the adrenergic and neuropeptide Y systems.

Changes in cerebral blood flow estimated after stellate ganglion block by single photon emission computed tomography

The validity of the hypothesis that the cerebral vasculature is under the control of sympathetic innervation was investigated using brain scintigraphy imaging before and after stellate ganglion block (SGB). The experiment with HM-PAO showed a definite increase in the blood flow of the brain on the block side on both by the dynamic images and the SPECT images. The tympanic temperature (Tty) of the block side decreased significantly after SGB, compared to the unblock side in this study, as had been reported before. This change in Tty coinsided with the increase in cerebral blood flow as mentioned above. This study demonstrated that the cerebral vasculature is under the control of sympathetic innervation, the pathway of which is relayed and/or passes through the stellate ganglion. We conclude that SGB increases intracerebral blood flow and can also exert secondary effects systemically due to CNS blood flow changes as have been previously reported.

Effects of body and head positions on bilateral difference in tympanic temperatures

We have examined the nonparallel changes in tympanic membrane temperatures (Tty) from the two ears in response to various changes in body and head positions. Upon assuming a lateral recumbent position, the Tty on the lower side increased while that on the upper side decreased. Pressure application over a wide area of the lateral chest only caused inconsistent and obscure asymmetric changes in Tty. A lateral flexion of the head with the subject sitting upright and a rotation of the head to the side in a supine position induced an increase in the Tty on the lower side compared to that on the upper side. The temperature and blood flow of the forehead often decreased on the lower side and increased on the upper side, although such responses were not always concomitant with the asymmetric changes in Tty. A dorsal flexion of the head with the subject in a reclining position caused a slight increase in the Tty, whereas raising the head upright induced a slight decrease in them. Two additional experiments were carried out with single photon emission computed tomography using 99mTc-hexamethylpropyleneamine oxime as tracer, and a slight, relative decrease in counts was noted in the right hemisphere during rotation of the head to the right. These results would strongly suggest that unilateral increases and decreases in Tty could have been caused by one-sided decreases and increases, respectively, in blood flow to the brain and/or the tympanic membrane, induced by a vasomotor reflex involving vestibular stimulation.

Regulation of regional cerebral blood flow by cholinergic fibers originating in the basal forebrain

We review mainly recent studies on vasodilative regulation of cortex and hippocampus by central cholinergic nerves originating in the basal forebrain. We also briefly review the influence of other central noradrenergic fibers originating in the locus ceruleus, serotonergic fibers originating in the dorsal raphe nucleus, dopaminergic fibers originating in the substantia nigra, and peripheral sympathetic and parasympathetic nerve fibers upon regulation of regional cerebral blood flow. Local metabolites have long been considered to play an important physiological role in regulating regional cerebral blood flow. However, the evidence reviewed here emphasizes that the regulation of regional cerebral blood flow by these central cholinergic nerves is independent of regional metabolism. We propose through this review that although studies investigating neural regulation of cortical and hippocampal blood flow by cholinergic fibers originating in the basal forebrain have added much to the understanding of regulation of regional cerebral blood flow further studies are needed to determine the physiological relevance of regional cerebral blood flow in relation to higher nervous functions such as memory, learning, and personality, and changes in these cognitive functions with aging and pathology such as Alzheimer's disease.

Acute sympathetic denervation does not eliminate the effect of angiotensin converting enzyme inhibition on CBF autoregulation in spontaneously hypertensive rats

The effect of angiotensin converting enzyme inhibition with captopril (10 mg/kg i.v.) on CBF autoregulation was studied in 16 spontaneously hypertensive rats (8 control and 8 treated with captopril) subjected to acute cervical sympathectomy. CBF was measured repetitively by the intra-arterial 133Xe injection method, during the manipulation of MABP by norepinephrine or hemorrhagic hypotension. Prior to the administration of drugs, baseline MABP was 112 +/- 10 mm Hg in the control group and 119 +/- 11 mm Hg in the captopril group. Baseline CBF was 99 +/- 19 ml/100 g/min, with no difference in the two groups. In agreement with previous findings in rats with intact sympathetic nerves, the lower limit of CBF autoregulation was reduced from the MABP interval of 70-89 to 50-69 mm Hg by captopril.

Angiotensin converting enzyme inhibition and the upper limit of cerebral blood flow autoregulation: effect of sympathetic stimulation

The effect of stimulation of the cervical sympathetic ganglia on the upper limit of cerebral blood flow (CBF) autoregulation was studied in normotensive Wistar-Kyoto rats (WKY) and in spontaneously hypertensive rats (SHR) following intravenous administration of the angiotensin converting enzyme inhibitor captopril (10 mg/kg). CBF was measured using the intracarotid 133Xe injection method in halothane/nitrous oxide anaesthetized WKY and SHR. Arterial blood pressure was raised stepwise by the intravenous infusion of noradrenaline. Toward the end of the study, Evans blue was injected and the brains examined for gross blood-brain barrier breakdown. In SHR, sympathetic stimulation reextended the upper limit of CBF autoregulation, which was at a mean arterial blood pressure level of 120-139 mm Hg in the control group of eight SHR and above 170 mm Hg in the stimulated group of nine SHR. In the group of nine WKY subjected to sympathetic stimulation, the upper limit of CBF autoregulation was reached at a mean arterial blood pressure level of 110-129 mm Hg as opposed to 90-109 mm Hg in a previous unstimulated group of WKY. In the two groups subjected to sympathetic stimulation, there was no extravasation of Evans blue in any of the brains. In the control group of SHR, in which there had been marked increases in CBF, three out of eight brains had foci with extravasation of the dye. It is concluded that in normotensive and in hypertensive rats sympathetic stimulation attenuates the downward shift of the upper limit of CBF autoregulation, which is known to accompany intravenous administration of captopril.

Cerebral circulation under normal and pathologic conditions

Autoregulation of the cerebral circulation is the regulating mechanism that keeps cerebral blood flow (CBF) constant within wide limits of arterial pressure. The lower limit is defined as the value of mean arterial pressure below which CBF decreases below the plateau, and the upper limit as the value of mean arterial pressure above which CBF increases above the plateau (60 and 150 mm Hg, respectively). Two possible mechanisms for autoregulation are discussed, myogenic response and metabolic regulation. Stimulation of the sympathetic nervous system and antagonism of the renin-angiotensin system modulate CBF autoregulation by shifting the entire curve toward higher or lower values of arterial pressure, respectively. The autoregulatory curve is shifted toward higher arterial pressures in chronic hypertension. Therefore, the tolerance to acute decreases in arterial pressure is impaired. Concomitantly, the tolerance of the brain to acute increases in arterial pressure is improved. This shift in the limits of autoregulation is due to structural and functional (hemodynamic) changes in the cerebral resistance vessels. These adaptive changes are partly reversible after chronic treatment with antihypertensive agents. The pathophysiology of autoregulation should be taken into consideration before drugs are used to decrease arterial pressure acutely.

Acetylcholinesterase-containing fibers and choline acetyltransferase activity in isolated cerebral microvessels from goats

Microvessels have been isolated from goat cerebral cortex and caudate nucleus. The purity of the preparations was assessed by light microscopy and by the high enrichment in the marker enzymes alkaline phosphatase and gamma-glutamyltransferase. Choline acetyltransferase activity was detected in the vascular fractions, being significantly higher in capillaries than in larger vessels. Acetylcholinesterase (AChE)-containing fibers were visualized in vessels of different caliber. Vessels with diameters larger than 70-90 microns showed a network pattern of fibers similar to that of pial arteries. In small vessels (10-70 microns) longitudinal or helical fibers were observed with occasional side-branches that surround the vessel. No AChE staining was visualized in isolated capillaries under light microscopy. This study shows that isolated intracerebral microvessels are suitable preparations for histochemical studies of perivascular nerves. Taken together, the biochemical and histological results are in accordance with a cholinergic innervation of the goat intracerebral vasculature.

Comparison between pial and intraparenchymal vascular responses to sympathetic stimulation under hypercapnic conditions. With special reference to the mechanism for escape phenomenon

We have shown that secondary vasodilation ('escape' phenomenon) during sympathetic nerve stimulation occurs in the intraparenchymal vessels but not remarkable in the pial vessels. To test a possible role of CO2 accumulation in the brain tissue in this phenomenon, the responses of pial and intraparenchymal vessels to sympathetic nerve stimulation were investigated during hypercapnia in 9 cats by using a video camera photoelectric system. The ipsilateral superior cervical ganglion was electrically stimulated for 5 min during hypercapnia (PaCO2 = 50 +/- 2 mm Hg). The intraparenchymal vessels as well as pial vessels remained constricted throughout the stimulation. Secondary dilation of the intraparenchymal vessels as seen at the later stage of sympathetic stimulation during normocapnia was not observed under the hypercapnic conditions. We assume that the arterial CO2 tension was so high that the constriction of inflow vessels could not result in accumulation of CO2 in the brain parenchyma. The accumulation of chemical metabolites as represented by CO2 is therefore considered to be the most probable mechanism underlying the escape phenomenon of the intraparenchymal vessels.