1
|
Ryman SG, Vakhtin AA, Mayer AR, van der Horn HJ, Shaff NA, Nitschke SR, Julio KR, Tarawneh RM, Rosenberg GA, Diaz SV, Pirio Richardson SE, Lin HC. Abnormal Cerebrovascular Activity, Perfusion, and Glymphatic Clearance in Lewy Body Diseases. Mov Disord 2024. [PMID: 38817039 DOI: 10.1002/mds.29867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/01/2024] [Accepted: 05/09/2024] [Indexed: 06/01/2024] Open
Abstract
Cerebrovascular activity is not only crucial to optimal cerebral perfusion, but also plays an important role in the glymphatic clearance of interstitial waste, including α-synuclein. This highlights a need to evaluate how cerebrovascular activity is altered in Lewy body diseases. This review begins by discussing how vascular risk factors and cardiovascular autonomic dysfunction may serve as upstream or direct influences on cerebrovascular activity. We then discuss how patients with Lewy body disease exhibit reduced and delayed cerebrovascular activity, hypoperfusion, and reductions in measures used to capture cerebrospinal fluid flow, suggestive of a reduced capacity for glymphatic clearance. Given the lack of an existing framework, we propose a model by which these processes may foster α-synuclein aggregation and neuroinflammation. Importantly, this review highlights several avenues for future research that may lead to treatments early in the disease course, prior to neurodegeneration. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
Collapse
Affiliation(s)
- Sephira G Ryman
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, The University of New Mexico, Albuquerque, New Mexico, USA
- Center for Memory and Aging, The University of New Mexico, Albuquerque, New Mexico, USA
| | - Andrei A Vakhtin
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Andrew R Mayer
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Harm Jan van der Horn
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Nicholas A Shaff
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Stephanie R Nitschke
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Kayla R Julio
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Rawan M Tarawneh
- Center for Memory and Aging, The University of New Mexico, Albuquerque, New Mexico, USA
- Cognitive Neurology Section, Department of Neurology, The University of New Mexico, Albuquerque, New Mexico, USA
| | - Gary A Rosenberg
- Center for Memory and Aging, The University of New Mexico, Albuquerque, New Mexico, USA
| | - Shanna V Diaz
- Department of Internal Medicine, The University of New Mexico, Albuquerque, New Mexico, USA
| | - Sarah E Pirio Richardson
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, The University of New Mexico, Albuquerque, New Mexico, USA
- New Mexico VA Health Care System, Albuquerque, New Mexico, USA
| | - Henry C Lin
- Department of Internal Medicine, The University of New Mexico, Albuquerque, New Mexico, USA
- New Mexico VA Health Care System, Albuquerque, New Mexico, USA
| |
Collapse
|
2
|
Mulvaney SW, Lynch JH, Rae Olmsted KL, Mahadevan S, Dineen KJ. The Successful Use of Bilateral 2-Level Ultrasound-Guided Stellate Ganglion Block to Improve Traumatic Brain Injury Symptoms: A Retrospective Analysis of 23 Patients. Mil Med 2024:usae193. [PMID: 38771000 DOI: 10.1093/milmed/usae193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/15/2024] [Accepted: 04/01/2024] [Indexed: 05/22/2024] Open
Abstract
PURPOSE The purpose of the study was to determine whether performing ultrasound-guided, bilateral stellate ganglion blocks (SGBs; performed on subsequent days) improved traumatic brain injury (TBI) symptoms. METHODS A retrospective chart review was conducted for the time period between August 2022 and February 2023 to identify patients who received bilateral, 2-level (C6 and C4) SGBs for PTSD symptoms but who also had a history of TBI. Neurobehavioral Symptoms Inventory (NSI) scores were collected at baseline, 1 week, and 1 month post-treatment in 14 males and 9 females. RESULTS Out of 23 patients, 22 showed improvement in their NSI scores. NSI baseline average score was 42.7; the average score at 1 week post-treatment was 18.8; 1 month post-treatment was 20.1. This represents a 53% improvement in the NSI score between baseline and 1 month. CONCLUSION The use of bilateral, 2-level SGBs may be indicated in treating patients with PTSD symptoms with concomitant diagnoses of mild-to-moderate TBI.
Collapse
Affiliation(s)
- Sean W Mulvaney
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | - James H Lynch
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | | | - Sanjay Mahadevan
- Regenerative Orthopedics and Sports Medicine, Annapolis, MD 21401, USA
| | - Kyle J Dineen
- Regenerative Orthopedics and Sports Medicine, Annapolis, MD 21401, USA
| |
Collapse
|
3
|
Carlson AP, Mayer AR, Cole C, van der Horn HJ, Marquez J, Stevenson TC, Shuttleworth CW. Cerebral autoregulation, spreading depolarization, and implications for targeted therapy in brain injury and ischemia. Rev Neurosci 2024; 0:revneuro-2024-0028. [PMID: 38581271 DOI: 10.1515/revneuro-2024-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
Cerebral autoregulation is an intrinsic myogenic response of cerebral vasculature that allows for preservation of stable cerebral blood flow levels in response to changing systemic blood pressure. It is effective across a broad range of blood pressure levels through precapillary vasoconstriction and dilation. Autoregulation is difficult to directly measure and methods to indirectly ascertain cerebral autoregulation status inherently require certain assumptions. Patients with impaired cerebral autoregulation may be at risk of brain ischemia. One of the central mechanisms of ischemia in patients with metabolically compromised states is likely the triggering of spreading depolarization (SD) events and ultimately, terminal (or anoxic) depolarization. Cerebral autoregulation and SD are therefore linked when considering the risk of ischemia. In this scoping review, we will discuss the range of methods to measure cerebral autoregulation, their theoretical strengths and weaknesses, and the available clinical evidence to support their utility. We will then discuss the emerging link between impaired cerebral autoregulation and the occurrence of SD events. Such an approach offers the opportunity to better understand an individual patient's physiology and provide targeted treatments.
Collapse
Affiliation(s)
- Andrew P Carlson
- Department of Neurosurgery, 12288 University of New Mexico School of Medicine , MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
- Department of Neurosciences, 12288 University of New Mexico School of Medicine , 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Andrew R Mayer
- 168528 Mind Research Network , 1101 Yale, Blvd, NE, Albuquerque, NM, 87106, USA
| | - Chad Cole
- Department of Neurosurgery, 12288 University of New Mexico School of Medicine , MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | - Harm J van der Horn
- 168528 Mind Research Network , 1101 Yale, Blvd, NE, Albuquerque, NM, 87106, USA
| | - Joshua Marquez
- 12288 University of New Mexico School of Medicine , 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Taylor C Stevenson
- Department of Neurosurgery, 12288 University of New Mexico School of Medicine , MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | - C William Shuttleworth
- Department of Neurosciences, 12288 University of New Mexico School of Medicine , 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| |
Collapse
|
4
|
van der Horn HJ, Vakhtin AA, Julio K, Nitschke S, Shaff N, Dodd AB, Erhardt E, Phillips JP, Pirio Richardson S, Deligtisch A, Stewart M, Suarez Cedeno G, Meles SK, Mayer AR, Ryman SG. Parkinson's disease cerebrovascular reactivity pattern: A feasibility study. J Cereb Blood Flow Metab 2024:271678X241241895. [PMID: 38578669 DOI: 10.1177/0271678x241241895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
A mounting body of research points to cerebrovascular dysfunction as a fundamental element in the pathophysiology of Parkinson's disease (PD). In the current feasibility study, blood-oxygen-level-dependent (BOLD) MRI was used to measure cerebrovascular reactivity (CVR) in response to hypercapnia in 26 PD patients and 16 healthy controls (HC), and aimed to find a multivariate pattern specific to PD. Whole-brain maps of CVR amplitude (i.e., magnitude of response to CO2) and latency (i.e., time to reach maximum amplitude) were computed, which were further analyzed using scaled sub-profile model principal component analysis (SSM-PCA) with leave-one-out cross-validation. A meaningful pattern based on CVR latency was identified, which was named the PD CVR pattern (PD-CVRP). This pattern was characterized by relatively increased latency in basal ganglia, sensorimotor cortex, supplementary motor area, thalamus and visual cortex, as well as decreased latency in the cerebral white matter, relative to HC. There were no significant associations with clinical measures, though sample size may have limited our ability to detect significant associations. In summary, the PD-CVRP highlights the importance of cerebrovascular dysfunction in PD, and may be a potential biomarker for future clinical research and practice.
Collapse
Affiliation(s)
- Harm Jan van der Horn
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Andrei A Vakhtin
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Kayla Julio
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Stephanie Nitschke
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Nicholas Shaff
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Andrew B Dodd
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Erik Erhardt
- Department of Mathematics and Statistics, University of New Mexico, Albuquerque, NM, USA
| | - John P Phillips
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Sarah Pirio Richardson
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, NM, USA
- New Mexico VA Health Care System, Albuquerque, NM, USA
| | - Amanda Deligtisch
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Melanie Stewart
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Gerson Suarez Cedeno
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Sanne K Meles
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Andrew R Mayer
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Sephira G Ryman
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| |
Collapse
|
5
|
Chi X, Jia B, Fu Q. Migraine after stellate ganglion block: A case report. Clin Case Rep 2023; 11:e8119. [PMID: 37915735 PMCID: PMC10616910 DOI: 10.1002/ccr3.8119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/07/2023] [Accepted: 10/12/2023] [Indexed: 11/03/2023] Open
Abstract
Stellate ganglion block-induced ipsilateral migraines are rare. We present a typical case detailing its developmental process. Abnormalities in the autonomic nervous system control and vascular and neural mechanisms may play crucial roles in the manifestation of these migraines. Postprocedural migraines necessitate anesthesiologists' awareness during stellate ganglion blocks.
Collapse
Affiliation(s)
- Xiaowei Chi
- Department of Anesthesiology, Third People's Hospital of ChengduSouthwest Jiaotong UniversityChengduChina
| | - Bin Jia
- Department of Cardiac Surgery, Third People's Hospital of ChengduSouthwest Jiaotong UniversityChengduChina
| | - Qiang Fu
- Department of Anesthesiology, Third People's Hospital of ChengduSouthwest Jiaotong UniversityChengduChina
| |
Collapse
|
6
|
Soliman OM, Aboulfotouh AI, Abdelhafez AM, Abedalmohsen A. Nebulized dexmedetomidine versus neostigmine/atropine for treating post-dural puncture headache after cesarean section: a double-blind randomized controlled trial. Minerva Anestesiol 2023; 89:867-875. [PMID: 36651373 DOI: 10.23736/s0375-9393.22.16906-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Post-dural puncture headache (PDPH) is one of the most common complications of neuraxial anesthesia after an accidental dural puncture. This study aimed to test non-interventional alternatives to treat PDPH. Our goals were to compare the effectiveness of nebulized dexmedetomidine (DEX) versus neostigmine/atropine in the conservative management of PDPH. METHODS A randomized double-blind controlled study of ninety (90) women divided into three equal groups: group C (given nebulization of saline 0.9% placebo in four mL), group N (given nebulization of 20 µ/kg neostigmine and 10 µ/kg atropine diluted in four mL normal saline), and group D (given nebulization of dexmedetomidine 1 µg/kg diluted in four mL normal saline). Nebulization was done twice daily for three days, and a Visual Analogue Scale pain score (VAS) was recorded for seventy-two hours after the intervention for the three groups with a VAS Score equal or less than three being the cutoff value. RESULTS VAS was significantly decreased in dexmedetomidine, and neostigmine/atropine groups compared to the control group at six hours (median VAS: 5, 2, and 2 for groups C, N, and D respectively [P=0.001]). There was a significant difference in VAS trends between the three groups (at six, twelve, twenty-four, thirty-six, and forty-eight hours [P=0.001], and at seventy-two hours [P=0.003]). No patients in group D, but one patient in group N and seven patients in group C needed an epidural blood patch. CONCLUSIONS Nebulized dexmedetomidine and neostigmine/atropine had a rapid effect on relieving PDPH after cesarean section.
Collapse
Affiliation(s)
- Omar M Soliman
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt -
| | - Ahmed I Aboulfotouh
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed M Abdelhafez
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Abualauon Abedalmohsen
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| |
Collapse
|
7
|
Matt RA, Martin RS, Evans AK, Gever JR, Vargas GA, Shamloo M, Ford AP. Locus Coeruleus and Noradrenergic Pharmacology in Neurodegenerative Disease. Handb Exp Pharmacol 2023. [PMID: 37495851 DOI: 10.1007/164_2023_677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Adrenoceptors (ARs) throughout the brain are stimulated by noradrenaline originating mostly from neurons of the locus coeruleus, a brainstem nucleus that is ostensibly the earliest to show detectable pathology in neurodegenerative diseases such as Alzheimer's and Parkinson's diseases. The α1-AR, α2-AR, and β-AR subtypes expressed in target brain regions and on a range of cell populations define the physiological responses to noradrenaline, which includes activation of cognitive function in addition to modulation of neurometabolism, cerebral blood flow, and neuroinflammation. As these heterocellular functions are critical for maintaining brain homeostasis and neuronal health, combating the loss of noradrenergic tone from locus coeruleus degeneration may therefore be an effective treatment for both cognitive symptoms and disease modification in neurodegenerative indications. Two pharmacologic approaches are receiving attention in recent clinical studies: preserving noradrenaline levels (e.g., via reuptake inhibition) and direct activation of target adrenoceptors. Here, we review the expression and role of adrenoceptors in the brain, the preclinical studies which demonstrate that adrenergic stimulation can support cognitive function and cerebral health by reversing the effects of noradrenaline depletion, and the human data provided by pharmacoepidemiologic analyses and clinical trials which together identify adrenoceptors as promising targets for the treatment of neurodegenerative disease.
Collapse
Affiliation(s)
| | | | - Andrew K Evans
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | | | - Mehrdad Shamloo
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | | |
Collapse
|
8
|
Zhao F, Tomita M, Dutta A. Operational Modal Analysis of Near-Infrared Spectroscopy Measure of 2-Month Exercise Intervention Effects in Sedentary Older Adults with Diabetes and Cognitive Impairment. Brain Sci 2023; 13:1099. [PMID: 37509027 PMCID: PMC10377417 DOI: 10.3390/brainsci13071099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/11/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
The Global Burden of Disease Study (GBD 2019 Diseases and Injuries Collaborators) found that diabetes significantly increases the overall burden of disease, leading to a 24.4% increase in disability-adjusted life years. Persistently high glucose levels in diabetes can cause structural and functional changes in proteins throughout the body, and the accumulation of protein aggregates in the brain that can be associated with the progression of Alzheimer's Disease (AD). To address this burden in type 2 diabetes mellitus (T2DM), a combined aerobic and resistance exercise program was developed based on the recommendations of the American College of Sports Medicine. The prospectively registered clinical trials (NCT04626453, NCT04812288) involved two groups: an Intervention group of older sedentary adults with T2DM and a Control group of healthy older adults who could be either active or sedentary. The completion rate for the 2-month exercise program was high, with participants completing on an average of 89.14% of the exercise sessions. This indicated that the program was practical, feasible, and well tolerated, even during the COVID-19 pandemic. It was also safe, requiring minimal equipment and no supervision. Our paper presents portable near-infrared spectroscopy (NIRS) based measures that showed muscle oxygen saturation (SmO2), i.e., the balance between oxygen delivery and oxygen consumption in muscle, drop during bilateral heel rise task (BHR) and the 6 min walk task (6MWT) significantly (p < 0.05) changed at the post-intervention follow-up from the pre-intervention baseline in the T2DM Intervention group participants. Moreover, post-intervention changes from pre-intervention baseline for the prefrontal activation (both oxyhemoglobin and deoxyhemoglobin) showed statistically significant (p < 0.05, q < 0.05) effect at the right superior frontal gyrus, dorsolateral, during the Mini-Cog task. Here, operational modal analysis provided further insights into the 2-month exercise intervention effects on the very-low-frequency oscillations (<0.05 Hz) during the Mini-Cog task that improved post-intervention in the sedentary T2DM Intervention group from their pre-intervention baseline when compared to active healthy Control group. Then, the 6MWT distance significantly (p < 0.01) improved in the T2DM Intervention group at post-intervention follow-up from pre-intervention baseline that showed improved aerobic capacity and endurance. Our portable NIRS based measures have practical implications at the point of care for the therapists as they can monitor muscle and brain oxygenation changes during physical and cognitive tests to prescribe personalized physical exercise doses without triggering individual stress response, thereby, enhancing vascular health in T2DM.
Collapse
Affiliation(s)
- Fei Zhao
- Department of Rehabilitation Science, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY 14214, USA
| | - Machiko Tomita
- Department of Rehabilitation Science, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY 14214, USA
| | - Anirban Dutta
- School of Engineering, University of Lincoln, Lincoln LN67TS, UK
| |
Collapse
|
9
|
Filippov AG, Alexandrin VV, Ivanov AV, Paltsyn AA, Sviridkina NB, Virus ED, Bulgakova PO, Burmiy JP, Kubatiev AA. Neuroprotective Effect of Platinum Nanoparticles Is Not Associated with Their Accumulation in the Brain of Rats. J Funct Biomater 2023; 14:348. [PMID: 37504843 PMCID: PMC10381480 DOI: 10.3390/jfb14070348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
Platinum nanoparticles (nPts) have neuroprotective/antioxidant properties, but the mechanisms of their action in cerebrovascular disease remain unclear. We investigated the brain bioavailability of nPts and their effects on brain damage, cerebral blood flow (CBF), and development of brain and systemic oxidative stress (OS) in a model of cerebral ischemia (hemorrhage + temporary bilateral common carotid artery occlusion, tBCAO) in rats. The nPts (0.04 g/L, 3 ± 1 nm diameter) were administered to rats (N = 19) intraperitoneally at the start of blood reperfusion. Measurement of CBF via laser Doppler flowmetry revealed that the nPts caused a rapid attenuation of postischemic hypoperfusion. The nPts attenuated the apoptosis of hippocampal neurons, the decrease in reduced aminothiols level in plasma, and the glutathione redox status in the brain, which were induced by tBCAO. The content of Pt in the brain was extremely low (≤1 ng/g). Thus, nPts, despite the extremely low brain bioavailability, can attenuate the development of brain OS, CBF dysregulation, and neuronal apoptosis. This may indicate that the neuroprotective effects of nPts are due to indirect mechanisms rather than direct activity in the brain tissue. Research on such mechanisms may offer a promising trend in the treatment of acute disorders of CBF.
Collapse
Affiliation(s)
| | | | | | - Alexander Alexandrovich Paltsyn
- Institute of General Pathology and Pathophysiology, Baltiyskaya St., 8, 125315 Moscow, Russia
- Russian Medical Academy for Continuing Professional Education, Barricadnaya St., 2/1 b. 1, 125993 Moscow, Russia
| | | | | | | | - Joanna Petrovna Burmiy
- Institute of Microelectronic Technology and Ultra-High-Purity Materials, Akademika Osip'yana Str., 6, 142432 Chernogolovka, Russia
| | - Aslan Amirkhanovich Kubatiev
- Institute of General Pathology and Pathophysiology, Baltiyskaya St., 8, 125315 Moscow, Russia
- Russian Medical Academy for Continuing Professional Education, Barricadnaya St., 2/1 b. 1, 125993 Moscow, Russia
| |
Collapse
|
10
|
Dumančić D, Stupin A, Kožul M, Šerić V, Kibel A, Goswami N, Brix B, Debeljak Ž, Scitovski R, Drenjančević I. Increased cerebral vascular resistance underlies preserved cerebral blood flow in response to orthostasis in humans on a high-salt diet. Eur J Appl Physiol 2023; 123:923-933. [PMID: 36598577 DOI: 10.1007/s00421-022-05124-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/20/2022] [Indexed: 01/05/2023]
Abstract
Cerebral blood flow autoregulation protects brain tissue from blood pressure variations and maintains cerebral perfusion pressure by changes in vascular resistance. High salt (HS) diet impairs endothelium-dependent vasodilation in many vascular beds, including cerebral microcirculation, and may affect vascular resistance. The aim of present study was to determine if 7-day HS diet affected the reactivity of middle cerebral artery (MCA) to orthostatic challenge in healthy human individuals, and if autoregulatory mechanisms and sympathetic neural regulation were involved in this phenomenon.Twenty-seven persons participated in study (F:21, M:6, age range 19-24). Participants consumed 7-day low-salt (LS) diet (< 2.3 g kitchen salt/day) and afterwards 7-day HS diet (> 11.2 g kitchen salt/day). Blood and urine analysis and anthropometric measurements were performed after each diet. Arterial blood pressure, heart rate and heart rate variability, and cerebral and systemic hemodynamic parameters were recorded simultaneously with transcranial Doppler ultrasound and The Task Force® Monitor in response to orthostatic test.Participants remained normotensive during HS diet. Following both, the LS and HS dietary protocols, mean cerebral blood flow (CBF), as well as the velocity time integral and diastolic blood pressure decreased, and cerebral pulsatility index increased after rising up. Importantly, cerebrovascular resistance significantly increased in response to orthostasis only after HS diet. Urine concentration of noradrenaline and vanillylmandelic acid, baroreflex sensitivity (BRS), and sympathetic neural control was significantly decreased in HS diet.Results suggest that CBF in response to orthostatic test was preserved in HS condition due to altered vascular reactivity of MCA, with increased cerebrovascular resistance and blunted BRS and sympathetic activity.
Collapse
Affiliation(s)
- Dijana Dumančić
- Department of Physiology and Immunology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000, Osijek, Croatia
- Department of Diagnostic and Interventional Radiology, University Hospital Centre Osijek, J. Huttlera 4, 31000, Osijek, Croatia
| | - Ana Stupin
- Department of Physiology and Immunology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000, Osijek, Croatia
| | - Maja Kožul
- Department of Dermatology and Venereology, University Hospital Centre Osijek, J. Huttlera 4, 31000, Osijek, Croatia
| | - Vatroslav Šerić
- Department of Clinical Laboratory Diagnostics, University Hospital Centre Osijek, J. Huttlera 4, 31000, Osijek, Croatia
| | - Aleksandar Kibel
- Department of Physiology and Immunology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000, Osijek, Croatia
- Department of Heart and Vascular Diseases, University Hospital Centre Osijek, J. Huttlera 4, 31000, Osijek, Croatia
| | - Nandu Goswami
- Physiology Division, Otto Loewi Research Center, Medical University of Graz, Auenbruggerplatz 2, 8036, Graz, Austria
| | - Bianca Brix
- Physiology Division, Otto Loewi Research Center, Medical University of Graz, Auenbruggerplatz 2, 8036, Graz, Austria
| | - Željko Debeljak
- Department of Clinical Laboratory Diagnostics, University Hospital Centre Osijek, J. Huttlera 4, 31000, Osijek, Croatia
- Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000, Osijek, Croatia
| | - Rudolf Scitovski
- Department of Mathematics, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Ines Drenjančević
- Department of Physiology and Immunology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000, Osijek, Croatia.
| |
Collapse
|
11
|
Zhang Q, Sui C, Cho J, Yang L, Chen T, Guo B, Gillen KM, Li J, Guo L, Wang Y. Assessing Cerebral Oxygen Metabolism Changes in Patients With Preeclampsia Using Voxel-Based Morphometry of Oxygen Extraction Fraction Maps in Magnetic Resonance Imaging. Korean J Radiol 2023; 24:324-337. [PMID: 36907593 PMCID: PMC10067693 DOI: 10.3348/kjr.2022.0652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 01/02/2023] [Accepted: 01/28/2023] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVE The objective of this study was to analyze the different brain oxygen metabolism statuses in preeclampsia using magnetic resonance imaging and investigate the factors that affect cerebral oxygen metabolism in preeclampsia. MATERIALS AND METHODS Forty-nine women with preeclampsia (mean age 32.4 years; range, 18-44 years), 22 pregnant healthy controls (PHCs) (mean age 30.7 years; range, 23-40 years), and 40 non-pregnant healthy controls (NPHCs) (mean age 32.5 years; range, 20-42 years) were included in this study. Brain oxygen extraction fraction (OEF) values were computed using quantitative susceptibility mapping (QSM) plus quantitative blood oxygen level-dependent magnitude-based OEF mapping (QSM + quantitative blood oxygen level-dependent imaging or QQ) obtained with a 1.5-T scanner. Voxel-based morphometry (VBM) was used to investigate the differences in OEF values in the brain regions among the groups. RESULTS Among the three groups, the average OEF values were significantly different in multiple brain areas, including the parahippocampus, multiple gyri of the frontal lobe, calcarine, cuneus, and precuneus (all P-values were less than 0.05, after correcting for multiple comparisons). The average OEF values of the preeclampsia group were higher than those of the PHC and NPHC groups. The bilateral superior frontal gyrus/bilateral medial superior frontal gyrus had the largest size of the aforementioned brain regions, and the OEF values in this area were 24.2 ± 4.6, 21.3 ± 2.4, and 20.6 ± 2.8 in the preeclampsia, PHC, and NPHC groups, respectively. In addition, the OEF values showed no significant differences between NPHC and PHC. Correlation analysis revealed that the OEF values of some brain regions (mainly involving the frontal, occipital, and temporal gyrus) were positively correlated with age, gestational week, body mass index, and mean blood pressure in the preeclampsia group (r = 0.361-0.812). CONCLUSION Using whole-brain VBM analysis, we found that patients with preeclampsia had higher OEF values than controls.
Collapse
Affiliation(s)
- Qihao Zhang
- Department of Radiology, Weill Cornell Medical College, New York, NY, USA
| | - Chaofan Sui
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Junghun Cho
- Department of Biomedical Engineering, University at Buffalo, The State University of New York, New York, NY, USA
| | - Linfeng Yang
- Department of Radiology, Jinan Maternity and Child Care Hospital, Jinan, Shandong, China
| | - Tao Chen
- Department of Clinical Laboratory, Jinan Maternity and Child Care Hospital, Jinan, Shandong, China
| | - Bin Guo
- Department of Radiology, Jinan Maternity and Child Care Hospital, Jinan, Shandong, China
| | | | - Jing Li
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
| | - Lingfei Guo
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.
| | - Yi Wang
- Department of Radiology, Weill Cornell Medical College, New York, NY, USA
| |
Collapse
|
12
|
Pfurtscheller D, Wolfsberger CH, Höller N, Schwaberger B, Mileder LP, Baik-Schneditz N, Urlesberger B, Schmölzer GM, Pichler G. Cardiac output and regional-cerebral-oxygen-saturation in preterm neonates during immediate postnatal transition: An observational study. Acta Paediatr 2023. [PMID: 36880893 DOI: 10.1111/apa.16745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/08/2023]
Abstract
AIM To examine potential correlations between cardiac output (CO) with cerebral-regional-oxygen-saturation (crSO2 ) and cerebral-fractional-tissue-oxygen-extraction (cFTOE) during immediate foetal-to-neonatal transition in term and preterm neonates with and without respiratory support. METHODS Post hoc analyses of secondary outcome parameters of prospective observational studies were performed. We included neonates with cerebral near-infrared-spectroscopy (NIRS) monitoring and an oscillometric blood pressure measurement at minute 15 after birth. Heart rate (HR) and arterial oxygen saturation (SpO2 ) were monitored. CO was calculated with Liljestrand and Zander formula and correlated with crSO2 and cFTOE. RESULTS Seventy-nine preterm neonates and 207 term neonates with NIRS measurements and calculated CO were included. In 59 preterm neonates (mean gestational age (GA): 29.4 ± 3.7 weeks) with respiratory support, CO correlated significantly positively with crSO2 and significantly negatively with cFTOE. In 20 preterm neonates (GA 34.9 ± 1.3 weeks) without respiratory support and in 207 term neonates with and without respiratory support, CO correlated neither with crSO2 nor with cFTOE. CONCLUSION In compromised preterm neonates with lower gestational age and in need of respiratory support, CO was associated with crSO2 and cFTOE, whereas in stable preterm neonates with higher gestational age as well as in term neonates with and without respiratory support, no associations were observed.
Collapse
Affiliation(s)
- Daniel Pfurtscheller
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Christina H Wolfsberger
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nina Höller
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Lukas P Mileder
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nariae Baik-Schneditz
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, Division of Neonatology Department of Pediatrics and Adolescent Medicine Medical, University of Alberta, Edmonton, Alberta, Canada
| | - Gerhard Pichler
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| |
Collapse
|
13
|
Mankoo A, Roy S, Davies A, Panerai RB, Robinson TG, Brassard P, Beishon LC, Minhas JS. The role of the autonomic nervous system in cerebral blood flow regulation in stroke: A review. Auton Neurosci 2023; 246:103082. [PMID: 36870192 DOI: 10.1016/j.autneu.2023.103082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 11/22/2022] [Accepted: 02/22/2023] [Indexed: 03/02/2023]
Abstract
Stroke is a pathophysiological condition which results in alterations in cerebral blood flow (CBF). The mechanism by which the brain maintains adequate CBF in presence of fluctuating cerebral perfusion pressure (CPP) is known as cerebral autoregulation (CA). Disturbances in CA may be influenced by a number of physiological pathways including the autonomic nervous system (ANS). The cerebrovascular system is innervated by adrenergic and cholinergic nerve fibers. The role of the ANS in regulating CBF is widely disputed owing to several factors including the complexity of the ANS and cerebrovascular interactions, limitations to measurements, variation in methods to assess the ANS in relation to CBF as well as experimental approaches that can or cannot provide insight into the sympathetic control of CBF. CA is known to be impaired in stroke however the number of studies investigating the mechanisms by which this occurs are limited. This literature review will focus on highlighting the assessment of the ANS and CBF via indices derived from the analyses of heart rate variability (HRV), and baroreflex sensitivity (BRS), and providing a summary of both clinical and animal model studies investigating the role of the ANS in influencing CA in stroke. Understanding the mechanisms by which the ANS influences CBF in stroke patients may provide the foundation for novel therapeutic approaches to improve functional outcomes in stroke patients.
Collapse
Affiliation(s)
- Alex Mankoo
- University of Leicester, Department of Cardiovascular Sciences, Leicester, United Kingdom
| | - Sankanika Roy
- University of Leicester, Department of Cardiovascular Sciences, Leicester, United Kingdom.
| | - Aaron Davies
- University of Leicester, Department of Cardiovascular Sciences, Leicester, United Kingdom
| | - Ronney B Panerai
- University of Leicester, Department of Cardiovascular Sciences, Leicester, United Kingdom; NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Thompson G Robinson
- University of Leicester, Department of Cardiovascular Sciences, Leicester, United Kingdom; NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, QC, Canada; Research center of the Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec, QC, Canada
| | - Lucy C Beishon
- University of Leicester, Department of Cardiovascular Sciences, Leicester, United Kingdom
| | - Jatinder S Minhas
- University of Leicester, Department of Cardiovascular Sciences, Leicester, United Kingdom; NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom
| |
Collapse
|
14
|
Profile of precipitating factors and its implication in 160 Indian patients with Moyamoya angiopathy. J Neurol 2023; 270:1654-1661. [PMID: 36477636 PMCID: PMC9734856 DOI: 10.1007/s00415-022-11499-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Moyamoya angiopathy (MMA) has been known to manifest with myriad of neurological manifestations, often in association with various precipitating factors. This is the first study to systematically analyze the precipitating triggers to neurological symptoms done on the largest cohort of MMA in India. METHODS A single-centered, cross-sectional observational study, recruiting 160 patients with consecutive angiographically proven MMA over a period of 5 years (2016-2021), was undertaken to evaluate the profile of immediate precipitating factors in temporal association to the neurological symptoms, along with their clinical and radiological characteristics. SPSS 25 was used for statistical analysis. RESULTS Among the 160 patients (Adult-85, children-75), precipitating factors were seen in 41.3%, significantly higher in children (52%) than adults (31.8%) (p value: 0.011). The commonest triggers included fever (18.8%), emotional stress (8.1%), heavy exercise and diarrhea (6.3% each). Cold bath triggered MMA symptoms in 1.3%. Fever (p value: 0.008) and persistent crying (p value: 0.010) triggered neurological symptoms more commonly in children than in adults. Amongst MMA patients with precipitating factors, the commonest MMA presentation included cerebral infarction type (37.9%) and TIA (31.8%). The majority of precipitating factors that preceded an ischemic event were BP-lowing ones (54.7%). CONCLUSION Neurological symptoms of MMA are commonly associated with several precipitating factors, including the lesser known triggers like cold bath. The frequency and profile precipitating factors varies with the age of presentation and type of MMA. It can serve as an early clue to the diagnosis of MMA and its careful avoidance can be largely beneficial in limiting the distressing transient neurological symptoms.
Collapse
|
15
|
Comparison of Equiosmolar Doses of 7.5% Hypertonic Saline and 20% Mannitol on Cerebral Oxygenation Status and Release of Brain Injury Markers During Supratentorial Craniotomy: A Randomized Controlled Trial. J Neurosurg Anesthesiol 2023; 35:56-64. [PMID: 34267156 DOI: 10.1097/ana.0000000000000791] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 06/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hyperosmolar therapy is the mainstay of treatment to reduce brain bulk and optimize surgical exposure during craniotomy. This study investigated the effect of equiosmolar doses of 7.5% hypertonic saline (HTS) and 20% mannitol on intraoperative cerebral oxygenation and metabolic status, systemic hemodynamics, brain relaxation, markers of cerebral injury, and perioperative craniotomy outcomes. METHODS A total of 51 patients undergoing elective supratentorial craniotomy were randomly assigned to receive 7.5% HTS (2 mL/kg) or 20% mannitol (4.6 mL/kg) at scalp incision. Intraoperative arterial and jugular bulb blood samples were collected at predefined time intervals for assessment of various indices of cerebral oxygenation; multiple hemodynamic variables were concomitantly recorded. S100B protein and neuron-specific enolase levels were determined at baseline, and at 6 and 12 hours after surgery for assessment of neuronal injury. Brain relaxation and perioperative outcomes were also assessed. RESULTS Demographic and intraoperative data, brain relaxation score, and perioperative outcomes were comparable between groups. Jugular bulb oxygen saturation and partial pressure of oxygen, arterial-jugular oxygen and carbon dioxide differences, and brain oxygen extraction ratio were favorably affected by 7.5% HTS up to 240 minutes postinfusion ( P <0.05), whereas mannitol was associated with only a short-lived (up to 15 min) improvement of these indices ( P <0.05). The changes in cerebral oxygenation corresponded to transient expansion of intravascular volume and improvements of cardiovascular performance. Increases in S100B and neuron-specific enolase levels at 6 and 12 hours after surgery ( P <0.0001) were comparable between groups. CONCLUSIONS The conclusion is that 7.5% HTS has a more beneficial effect on cerebral oxygenation than an equiosmolar dose of 20% mannitol during supratentorial craniotomy, yet no clear-cut clinical superiority of either solution could be demonstrated.
Collapse
|
16
|
Khadka N, Bikson M. Neurocapillary-Modulation. Neuromodulation 2022; 25:1299-1311. [PMID: 33340187 PMCID: PMC8213863 DOI: 10.1111/ner.13338] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/05/2020] [Accepted: 11/23/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES We consider two consequences of brain capillary ultrastructure in neuromodulation. First, blood-brain barrier (BBB) polarization as a consequence of current crossing between interstitial space and the blood. Second, interstitial current flow distortion around capillaries impacting neuronal stimulation. MATERIALS AND METHODS We developed computational models of BBB ultrastructure morphologies to first assess electric field amplification at the BBB (principle 1) and neuron polarization amplification by the presence of capillaries (principle 2). We adapt neuron cable theory to develop an analytical solution for maximum BBB polarization sensitivity. RESULTS Electrical current crosses between the brain parenchyma (interstitial space) and capillaries, producing BBB electric fields (EBBB) that are >400x of the average parenchyma electric field (ĒBRAIN), which in turn modulates transport across the BBB. Specifically, for a BBB space constant (λBBB) and wall thickness (dth-BBB), the analytical solution for maximal BBB electric field (EABBB) is given as: (ĒBRAIN × λBBB)/dth-BBB. Electrical current in the brain parenchyma is distorted around brain capillaries, amplifying neuronal polarization. Specifically, capillary ultrastructure produces ∼50% modulation of the ĒBRAIN over the ∼40 μm inter-capillary distance. The divergence of EBRAIN (Activating function) is thus ∼100 kV/m2 per unit ĒBRAIN. CONCLUSIONS BBB stimulation by principle 1 suggests novel therapeutic strategies such as boosting metabolic capacity or interstitial fluid clearance. Whereas the spatial profile of EBRAIN is traditionally assumed to depend only on macroscopic anatomy, principle 2 suggests a central role for local capillary ultrastructure-which impact forms of neuromodulation including deep brain stimulation (DBS), spinal cord stimulation (SCS), transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT), and transcranial electrical stimulation (tES)/transcranial direct current stimulation (tDCS).
Collapse
Affiliation(s)
- Niranjan Khadka
- Department of Psychiatry, Laboratory for Neuropsychiatry and Neuromodulation, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Marom Bikson
- Department of Biomedical Engineering, The City College of New York, CUNY, New York, NY, USA.
| |
Collapse
|
17
|
Toro C, Ohnuma T, Komisarow J, Vavilala MS, Laskowitz DT, James ML, Mathew JP, Hernandez AF, Goldstein BA, Sampson JH, Krishnamoorthy V. Early Vasopressor Utilization Strategies and Outcomes in Critically Ill Patients With Severe Traumatic Brain Injury. Anesth Analg 2022; 135:1245-1252. [PMID: 35203085 PMCID: PMC9381646 DOI: 10.1213/ane.0000000000005949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Early hypotension after severe traumatic brain injury (sTBI) is associated with increased mortality and poor long-term outcomes. Current guidelines suggest the use of intravenous vasopressors, commonly norepinephrine and phenylephrine, to support blood pressure after TBI. However, guidelines do not specify vasopressor type, resulting in variation in clinical practice. We describe early vasopressor utilization patterns in critically ill patients with TBI and examine the association between utilization of norepinephrine, compared to phenylephrine, with hospital mortality after sTBI. METHODS We conducted a retrospective cohort study of US hospitals participating in the Premier Healthcare Database between 2009 and 2018. We examined adult patients (>17 years of age) with a primary diagnosis of sTBI who were treated in an intensive care unit (ICU) after injury. The primary exposure was vasopressor choice (phenylephrine versus norepinephrine) within the first 2 days of hospital admission. The primary outcome was in-hospital mortality. Secondary outcomes examined included hospital length of stay (LOS) and ICU LOS. We conducted a post hoc subgroup analysis in all patients with intracranial pressure (ICP) monitor placement. Regression analysis was used to assess differences in outcomes between patients exposed to phenylephrine versus norepinephrine, with propensity matching to address selection bias due to the nonrandom allocation of treatment groups. RESULTS From 2009 to 2018, 24,718 (37.1%) of 66,610 sTBI patients received vasopressors within the first 2 days of hospitalization. Among these patients, 60.6% (n = 14,991) received only phenylephrine, 10.8% (n = 2668) received only norepinephrine, 3.5% (n = 877) received other vasopressors, and 25.0% (n = 6182) received multiple vasopressors. In that time period, the use of all vasopressors after sTBI increased. A moderate degree of variation in vasopressor choice was explained at the individual hospital level (23.1%). In propensity-matched analysis, the use of norepinephrine compared to phenylephrine was associated with an increased risk of in-hospital mortality (OR, 1.65; CI, 1.46-1.86; P < .0001). CONCLUSIONS Early vasopressor utilization among critically ill patients with sTBI is common, increasing over the last decade, and varies across hospitals caring for TBI patients. Compared to phenylephrine, norepinephrine was associated with increased risk of in-hospital mortality in propensity-matched analysis. Given the wide variation in vasopressor utilization and possible differences in efficacy, our analysis suggests the need for randomized controlled trials to better inform vasopressor choice for patients with sTBI.
Collapse
Affiliation(s)
- Camilo Toro
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Duke University School of Medicine. Durham, NC
| | - Tetsu Ohnuma
- Department of Anesthesiology, Duke University. Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Departments of Biostatistics and Bioinformatics, Duke University. Durham, NC
| | - Jordan Komisarow
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Neurosurgery, Duke University. Durham, NC
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington. Seattle, WA
| | - Daniel T. Laskowitz
- Department of Anesthesiology, Duke University. Durham, NC
- Department of Neurology, Duke University. Durham, NC
- Department of Neurosurgery, Duke University. Durham, NC
| | - Michael L. James
- Department of Anesthesiology, Duke University. Durham, NC
- Department of Neurology, Duke University. Durham, NC
| | | | | | - Ben A. Goldstein
- Departments of Biostatistics and Bioinformatics, Duke University. Durham, NC
| | | | - Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University. Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University. Durham, NC
| |
Collapse
|
18
|
Marmarelis VZ, Shin DC, Hamner JW, Tan CO. Dynamic effects of cholinergic blockade upon cerebral blood flow autoregulation in healthy adults. Front Physiol 2022; 13:1015544. [PMID: 36406984 PMCID: PMC9666788 DOI: 10.3389/fphys.2022.1015544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/05/2022] [Indexed: 01/25/2023] Open
Abstract
Background: Cerebral flow autoregulation (CFA) is a homeostatic mechanism critical for survival. The autonomic nervous system (ANS) plays a key role in maintaining proper CFA function. More quantitative studies of how the ANS influences CFA are desirable. Objective: To discover and quantify the dynamic effects of cholinergic blockade upon CFA in response to changes of arterial blood pressure and blood CO2 tension in healthy adults. Methods: We analyzed time-series data of spontaneous beat-to-beat mean arterial blood pressure (ABP) and cerebral blood flow velocity in the middle cerebral arteries (CFV), as well as breath-to-breath end-tidal CO2 (CO2), collected in 9 adults before and after cholinergic blockade, in order to obtain subject-specific predictive input-output models of the dynamic effects of changes in ABP and CO2 (inputs) upon CFV (output). These models are defined in convolutional form using "kernel" functions (or, equivalently, Transfer Functions in the frequency domain) that are estimated via the robust method of Laguerre expansions. Results: Cholinergic blockade caused statistically significant changes in the obtained kernel estimates (and the corresponding Transfer Functions) that define the linear dynamics of the ABP-to-CFV and CO2-to-CFV causal relations. The kernel changes due to cholinergic blockade reflect the effects of the cholinergic mechanism and exhibited, in the frequency domain, resonant peaks at 0.22 Hz and 0.06 Hz for the ABP-to-CFV and CO2-to-CFV dynamics, respectively. Conclusion: Quantitative estimates of the dynamics of the cholinergic component in CFA are found as average changes of the ABP-to-CFV and CO2-to-CFV kernels, and corresponding Transfer Functions, before and after cholinergic blockade.
Collapse
Affiliation(s)
- Vasilis Z. Marmarelis
- Biomedical Engineering, University of Southern CA, Los Angeles, MA, United States,*Correspondence: Vasilis Z. Marmarelis,
| | - Dae C. Shin
- Biomedical Engineering, University of Southern CA, Los Angeles, MA, United States
| | - Jason W. Hamner
- Cardiovascular Research Laboratory, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Can Ozan Tan
- Electrical Engineering Math and Computer Science, University of Twente, Enschede, Netherlands
| |
Collapse
|
19
|
OpenBloodFlow: A User-Friendly OpenCV-Based Software Package for Blood Flow Velocity and Blood Cell Count Measurement for Fish Embryos. BIOLOGY 2022; 11:biology11101471. [PMID: 36290375 PMCID: PMC9598615 DOI: 10.3390/biology11101471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 09/22/2022] [Accepted: 09/30/2022] [Indexed: 11/16/2022]
Abstract
The transparent appearance of fish embryos provides an excellent assessment feature for observing cardiovascular function in vivo. Previously, methods to conduct vascular function assessment were based on measuring blood-flow velocity using third-party software. In this study, we reported a simple software, free of costs and skills, called OpenBloodFlow, which can measure blood flow velocity and count blood cells in fish embryos for the first time. First, videos captured by high-speed CCD were processed for better image stabilization and contrast. Next, the optical flow of moving objects was extracted from the non-moving background in a frame-by-frame manner. Finally, blood flow velocity was calculated by the Gunner Farneback algorithm in Python. Data validation with zebrafish and medaka embryos in OpenBloodFlow was consistent with our previously published ImageJ-based method. We demonstrated consistent blood flow alterations by either OpenBloodFlow or ImageJ in the dorsal aorta of zebrafish embryos when exposed to either phenylhydrazine or ractopamine. In addition, we validated that OpenBloodFlow was able to conduct precise blood cell counting. In this study, we provide an easy and fully automatic programming for blood flow velocity calculation and blood cell counting that is useful for toxicology and pharmacology studies in fish.
Collapse
|
20
|
Keijzer HM, Lange PA, Meijer FJ, Tonino BA, Blans MJ, Klijn CJ, Hoedemaekers CW, Hofmeijer J, Helmich RC. MRI markers of brain network integrity relate to neurological outcome in postanoxic coma. Neuroimage Clin 2022; 36:103171. [PMID: 36058165 PMCID: PMC9446009 DOI: 10.1016/j.nicl.2022.103171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 12/14/2022]
Abstract
AIM Current multimodal approaches leave approximately half of the comatose patients after cardiac arrest with an indeterminate prognosis. Here we investigated whether early MRI markers of brain network integrity can distinguish between comatose patients with a good versus poor neurological outcome six months later. METHODS We performed a prospective cohort study in 48 patients after cardiac arrest submitted in a comatose state to the Intensive Care Unit of two Dutch hospitals. MRI was performed at three days after cardiac arrest, including resting state functional MRI and diffusion-tensor imaging (DTI). Resting state fMRI was used to quantify functional connectivity within ten resting-state networks, and DTI to assess mean diffusivity (MD) in these same networks. We contrasted two groups of patients, those with good (n = 29, cerebral performance category 1-2) versus poor (n = 19, cerebral performance category 3-5) outcome at six months. Mutual associations between functional connectivity, MD, and clinical outcome were studied. RESULTS Patients with good outcome show higher within-network functional connectivity (fMRI) and higher MD (DTI) than patients with poor outcome across 8/10 networks, most prominent in the default mode network, salience network, and visual network. While the anatomical distribution of outcome-related changes was similar for functional connectivity and MD, the pattern of inter-individual differences was very different: functional connectivity showed larger inter-individual variability in good versus poor outcome, while the opposite was observed for MD. Exploratory analyses suggested that it is possible to define network-specific cut-off values that could help in outcome prediction: (1) high functional connectivity and high MD, associated with good outcome; (2) low functional connectivity and low MD, associated with poor outcome; (3) low functional connectivity and high MD, associated with uncertain outcome. DISCUSSION Resting-state functional connectivity and mean diffusivity-three days after cardiac arrest are strongly associated with neurological recovery-six months later in a complementary fashion. The combination of fMRI and MD holds potential to improve prediction of outcome.
Collapse
Affiliation(s)
- Hanneke M. Keijzer
- Department of Neurology, Rijnstate Hospital, 6800 TA Arnhem, the Netherlands,Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands,Corresponding author at: Department of Neurology, Rijnstate Hospital, PO box 9555 TA Arnhem, the Netherlands.
| | - Puck A.M. Lange
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands
| | - Frederick J.A. Meijer
- Department of Medical Imaging, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands
| | - Bart A.R. Tonino
- Department of Radiology, Rijnstate Hospital, 6800 TA Arnhem, the Netherlands
| | - Michiel J. Blans
- Department of Intensive Care Medicine, Rijnstate Hospital, Arnhem, the Netherlands
| | - Catharina J.M. Klijn
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands
| | - Cornelia W.E. Hoedemaekers
- Department of Intensive Care Medicine, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, 6800 TA Arnhem, the Netherlands,Department of Clinical Neurophysiology, University of Twente, Faculty of Science and Technology, 7522 NB Enschede, the Netherlands
| | - Rick C. Helmich
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands
| |
Collapse
|
21
|
Lehrer H, Dayan I, Elkayam K, Kfir A, Bierman U, Front L, Catz A, Aidinoff E. Responses to stimuli in the 'snoezelen' room in unresponsive wakefulness or in minimally responsive state. Brain Inj 2022; 36:1167-1175. [PMID: 35978560 DOI: 10.1080/02699052.2022.2110286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Sensory stimulation in Snoezelen room increased responsiveness after brain injury and dementia. OBJECTIVE To explore the physiological and clinical effects of Snoezelen stimulation in persons with unresponsive wakefulness syndrome or minimally conscious state (UWS or MCS). DESIGN A comparative prospective observational cohort study. METHODS Ten patients with UWS and 25 in MCS were exposed to consecutive stimuli involving the 5 senses in a Snoezelen room. Heart rate (HR) and cerebral blood flow velocity (CBFV), and scores of the Loewenstein communication scale (LCS) were obtained before and during or after the stimuli. RESULTS The stimuli increased HR values and decreased left hemisphere CBFV values in patients with MCS (p < 0.05). Stimulation increased LCS scores (from 28.48 ± 6.55 to 31.13 ± 7.14; p < 0.001) in patients with MCS, but not in the UWS group. LCS gain correlated with HR and right hemisphere CBFV gains in patients with MCS (r = 0.439 and 0.636 respectively, p < 0.05). CONCLUSIONS Snoezelen stimulation induced immediate improvement in communication and physiological changes in patients with MSC, and had a minor physiological effect in patients with UWS. If additional studies support these findings, it will be possible to suggest that Snoezelen stimulation can affect arousal, and possibly improve functioning.
Collapse
Affiliation(s)
- Hiela Lehrer
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Ilil Dayan
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Keren Elkayam
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Adi Kfir
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Uri Bierman
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Lilach Front
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Amiram Catz
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel.,Sackler Faculty of Medicine, Rehabilitation Department, Tel Aviv University, Tel Aviv, Israel
| | - Elena Aidinoff
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel.,Sackler Faculty of Medicine, Rehabilitation Department, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
22
|
Chauhan G, Upadhyay A, Khanduja S, Emerick T. Stellate Ganglion Block for Anosmia and Dysgeusia Due to Long COVID. Cureus 2022; 14:e27779. [PMID: 36106285 PMCID: PMC9450932 DOI: 10.7759/cureus.27779] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Anosmia and parosmia refer to the loss or dysfunction of smell, respectively. Dysgeusia refers to taste disturbance. The coronavirus disease 2019 (COVID-19) pandemic and the subsequent phenomenon of Long COVID syndrome have been associated with an increased incidence of anosmia and dysgeusia. Smell and taste disturbances associated with COVID-19 are usually self-limiting but can persist for longer periods in some cases. Imbalances of the autonomic nervous system, especially dysregulation of the sympathetic system, are implicated in the persistence of anosmia and dysgeusia post-COVID-19 infection. Stellate ganglion block (SGB) can diminish the increased sympathetic activity and potentially resolve anosmia and dysgeusia occurring due to Long COVID. The authors report the successful resolution of persistent anosmia and dysgeusia due to Long COVID in a female patient after she underwent SGB.
Collapse
|
23
|
Impact of Catheter Ablation on Brain Microstructure and Blood Flow Alterations for Cognitive Improvements in Patients with Atrial Fibrillation: A Pilot Longitudinal Study. J Clin Med 2022; 11:jcm11154346. [PMID: 35893438 PMCID: PMC9332426 DOI: 10.3390/jcm11154346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/08/2022] [Accepted: 07/23/2022] [Indexed: 12/04/2022] Open
Abstract
Atrial fibrillation (AF) predisposes patients to develop cognitive decline and dementia. Clinical and epidemiological data propose that catheter ablation may provide further benefit to improve neurocognitive function in patients with AF, but the underlying mechanism is poorly available. Here, we conducted a pilot prospective study to investigate whether AF ablation can alter regional cerebral blood flow (rCBF) and brain microstructures, using multimodal magnetic resonance imaging (MRI) technique. Eight patients (63 ± 7 years) with persistent AF underwent arterial-spin labeling (ASL) perfusion, 3D T1-structural images and cognitive test batteries before and 6 months after intervention. ASL and structural MR images were spatially normalized, and the rCBF and cortical thickness of different brain areas were compared between pre- and 6-month post-treatment. Cognitive–psychological function was improved, and rCBF was significantly increased in the left posterior cingulate cortex (PCC) (p = 0.013), whereas decreased cortical thickness was found in the left posterior insular cortex (p = 0.023). Given that the PCC is a strategic site in the limbic system, while the insular cortex is known to play an important part in the central autonomic nervous system, our findings extend the hypothesis that autonomic system alterations are an important mechanism explaining the positive effect of AF ablation on cognitive function.
Collapse
|
24
|
The Patent Foramen Ovale and Migraine: Associated Mechanisms and Perspectives from MRI Evidence. Brain Sci 2022; 12:brainsci12070941. [PMID: 35884747 PMCID: PMC9313384 DOI: 10.3390/brainsci12070941] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/10/2022] [Accepted: 07/15/2022] [Indexed: 02/04/2023] Open
Abstract
Migraine is a common neurological disease with a still-unclear etiology and pathogenesis. Patent foramen ovale (PFO) is a kind of congenital heart disease that leads to a right-to-left shunt (RLS). Although previous studies have shown that PFO has an effect on migraine, a clear conclusion about the link between PFO and migraine is lacking. We first summarized the PFO potential mechanisms associated with migraine, including microembolus-triggered cortical spreading depression (CSD), the vasoactive substance hypothesis, impaired cerebral autoregulation (CA), and a common genetic basis. Further, we analyzed the changes in brain structure and function in migraine patients and migraine patients with PFO. We found that in migraine patients with PFO, the presence of PFO may affect the structure of the cerebral cortex and the integrity of white matter, which is mainly locked in subcortical, deep white matter, and posterior circulation, and may lead to changes in brain function, such as cerebellum and colliculus, which are involved in the processing and transmission of pain. In summary, this paper provides neuroimaging evidence and new insights into the correlation between PFO and migraine, which will help to clarify the etiology and pathogenesis of migraine, and aid in the diagnosis and treatment of migraine in the future.
Collapse
|
25
|
Crippa IA, Pelosi P, Quispe-Cornejo AA, Messina A, Corradi F, Taccone FS, Robba C. Automated Pupillometry as an Assessment Tool for Intracranial Hemodynamics in Septic Patients. Cells 2022; 11:cells11142206. [PMID: 35883649 PMCID: PMC9319569 DOI: 10.3390/cells11142206] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/23/2022] [Accepted: 07/12/2022] [Indexed: 02/05/2023] Open
Abstract
Impaired cerebral autoregulation (CA) may increase the risk of brain hypoperfusion in septic patients. Sepsis dysregulates the autonomic nervous system (ANS), potentially affecting CA. ANS function can be assessed through the pupillary light reflex (PLR). The aim of this prospective, observational study was to investigate the association between CA and PLR in adult septic patients. Transcranial Doppler was used to assess CA and calculate estimated cerebral perfusion pressure (eCPP) and intracranial pressure (eICP). An automated pupillometer (AP) was used to record Neurological Pupil Index (NPi), constriction (CV) and dilation (DV) velocities. The primary outcome was the relationship between AP-derived variables with CA; the secondary outcome was the association between AP-derived variables with eCPP and/or eICP. Among 40 included patients, 21 (53%) had impaired CA, 22 (55%) had low eCPP (<60 mmHg) and 15 (38%) had high eICP (>16 mmHg). DV was lower in patients with impaired CA compared to others; DV predicted impaired CA with area under the curve, AUROC= 0.78 [95% Confidence Interval, CI 0.63−0.94]; DV < 2.2 mm/s had sensitivity 85% and specificity 69% for impaired CA. Patients with low eCPP or high eICP had lower NPi values than others. NPi was correlated with eCPP (r = 0.77, p < 0.01) and eICP (r = −0.87, p < 0.01). Automated pupillometry may play a role to assess brain hemodynamics in septic patients.
Collapse
Affiliation(s)
- Ilaria Alice Crippa
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium; (A.A.Q.-C.); (F.S.T.)
- Department of Anesthesiology and Intensive Care, San Marco Hospital, San Donato Group, 24040 Zingonia, Italy
- Correspondence:
| | - Paolo Pelosi
- Department of Anesthesiology and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132 Genoa, Italy; (P.P.); (C.R.)
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16132 Genoa, Italy
| | - Armin Alvaro Quispe-Cornejo
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium; (A.A.Q.-C.); (F.S.T.)
| | - Antonio Messina
- Humanitas Clinical and Research Center—IRCCS, 20089 Rozzano, Italy;
| | - Francesco Corradi
- Department of Surgical Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium; (A.A.Q.-C.); (F.S.T.)
| | - Chiara Robba
- Department of Anesthesiology and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132 Genoa, Italy; (P.P.); (C.R.)
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16132 Genoa, Italy
| |
Collapse
|
26
|
Skow RJ, Brothers RM, Claassen JAHR, Day TA, Rickards CA, Smirl JD, Brassard P. On the use and misuse of cerebral hemodynamics terminology using Transcranial Doppler ultrasound: a call for standardization. Am J Physiol Heart Circ Physiol 2022; 323:H350-H357. [PMID: 35839156 DOI: 10.1152/ajpheart.00107.2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cerebral hemodynamics (e.g., cerebral blood flow) can be measured and quantified using many different methods, with Transcranial Doppler ultrasound (TCD) being one of the most commonly utilized approaches. In human physiology, the terminology used to describe metrics of cerebral hemodynamics are inconsistent, and in some instances technically inaccurate; this is especially true when evaluating, reporting, and interpreting measures from TCD. Therefore, this perspectives article presents recommended terminology when reporting cerebral hemodynamic data. We discuss the current use and misuse of the terminology in the context of using TCD to measure and quantify cerebral hemodynamics and present our rationale and consensus on the terminology that we recommend moving forward. For example, one recommendation is to discontinue use of the term "cerebral blood flow velocity" in favor of "cerebral blood velocity" with precise indication of the vessel of interest. We also recommend clarity when differentiating between discrete cerebrovascular regulatory mechanisms, namely cerebral autoregulation, neurovascular coupling, and cerebrovascular reactivity. This will be a useful guide for investigators in the field of cerebral hemodynamics research.
Collapse
Affiliation(s)
- Rachel J Skow
- Department of Kinesiology, The University of Texas at Arlington, Arlington, TX, United States
| | - R Matthew Brothers
- Department of Kinesiology, The University of Texas at Arlington, Arlington, TX, United States
| | - Jurgen A H R Claassen
- Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Trevor A Day
- Department of Biology, Faculty of Science and Technology, Mount Royal University, Calgary, Alberta, Canada
| | - Caroline A Rickards
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, Texas, United States
| | - Jonathan D Smirl
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Cerebrovascular Concussion Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Integrated Concussion Research Program, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, Canada.,Research center of the Institut universitaire de cardiologie et de pneumologie de Québec, Canada
| |
Collapse
|
27
|
Muñoz V, Diaz‐Sanchez JA, Muñoz‐Caracuel M, Gómez CM. Head hemodynamics and systemic responses during auditory stimulation. Physiol Rep 2022; 10:e15372. [PMID: 35785451 PMCID: PMC9251853 DOI: 10.14814/phy2.15372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 06/15/2023] Open
Abstract
The present study aims to analyze the systemic response to auditory stimulation by means of hemodynamic (cephalic and peripheral) and autonomic responses in a broad range of auditory intensities (70.9, 77.9, 84.5, 89.5, 94.5 dBA). This approach could help to understand the possible influence of the autonomic nervous system on the cephalic blood flow. Twenty-five subjects were exposed to auditory stimulation while electrodermal activity (EDA), photoplethysmography (PPG), electrocardiogram, and functional near-infrared spectroscopy signals were recorded. Seven trials with 20 individual tones, each for the five intensities, were presented. The results showed a differentiated response to the higher intensity (94.5 dBA) with a decrease in some peripheral signals such as the heart rate (HR), the pulse signal, the pulse transit time (PTT), an increase of the LFnu power in PPG, and at the head level a decrease in oxygenated and total hemoglobin concentration. After the regression of the visual channel activity from the auditory channels, a decrease in deoxyhemoglobin in the auditory cortex was obtained, indicating a likely active response at the highest intensity. Nevertheless, other measures, such as EDA (Phasic and Tonic), and heart rate variability (Frequency and time domain) showed no significant differences between intensities. Altogether, these results suggest a systemic and complex response to high-intensity auditory stimuli. The results obtained in the decrease of the PTT and the increase in LFnu power of PPG suggest a possible vasoconstriction reflex by a sympathetic control of vascular tone, which could be related to the decrease in blood oxygenation at the head level.
Collapse
Affiliation(s)
- Vanesa Muñoz
- Human Psychobiology Laboratory, Experimental Psychology DepartmentUniversity of SevillaSevillaSpain
| | - José A. Diaz‐Sanchez
- Human Psychobiology Laboratory, Experimental Psychology DepartmentUniversity of SevillaSevillaSpain
| | - Manuel Muñoz‐Caracuel
- Human Psychobiology Laboratory, Experimental Psychology DepartmentUniversity of SevillaSevillaSpain
| | - Carlos M. Gómez
- Human Psychobiology Laboratory, Experimental Psychology DepartmentUniversity of SevillaSevillaSpain
| |
Collapse
|
28
|
Omran SS, Gutierrez J, Mohr JP, Elkind MS. Structural and Functional Characteristics of Cerebral Arteries as an Explanation for Clinical Syndromes Limited to the Brain. Cerebrovasc Dis 2022; 52:52-60. [PMID: 35675791 PMCID: PMC9729387 DOI: 10.1159/000524724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/25/2022] [Indexed: 02/04/2023] Open
Abstract
Vascular disease affects many different arterial beds throughout the body. Yet the brain is susceptible to several vascular disorders that either are not found in other parts of the body or when found are much less likely to cause clinical syndromes in other organs. This specific vulnerability of the brain may be explained by structural and functional differences between the vessels of the brain and those of vessels in other parts of the body. In this review, we focus on how cerebrovascular anatomy and physiology may make the brain and its vessels more susceptible to unique vascular pathologies. To highlight these differences, we use our knowledge of five diseases and syndromes that most commonly manifest in the intracranial vasculature. For each, we identify characteristics of the intracranial arteries that make them susceptible to these diseases, while noting areas of uncertainty requiring further research.
Collapse
Affiliation(s)
| | - Jose Gutierrez
- Vagelos College of Physicians and Surgeons, New York, NY
| | - Jay P. Mohr
- Vagelos College of Physicians and Surgeons, New York, NY
| | - Mitchell S.V. Elkind
- Vagelos College of Physicians and Surgeons, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY
| |
Collapse
|
29
|
Continuous Determination of the Optimal Bispectral Index Value Based on Cerebrovascular Reactivity in Moderate/Severe Traumatic Brain Injury: A Retrospective Observational Cohort Study of a Novel Individualized Sedation Target. Crit Care Explor 2022; 4:e0656. [PMID: 35265854 PMCID: PMC8901214 DOI: 10.1097/cce.0000000000000656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
30
|
Fan JL, Brassard P, Rickards CA, Nogueira RC, Nasr N, McBryde FD, Fisher JP, Tzeng YC. Integrative cerebral blood flow regulation in ischemic stroke. J Cereb Blood Flow Metab 2022; 42:387-403. [PMID: 34259070 PMCID: PMC8985438 DOI: 10.1177/0271678x211032029] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Optimizing cerebral perfusion is key to rescuing salvageable ischemic brain tissue. Despite being an important determinant of cerebral perfusion, there are no effective guidelines for blood pressure (BP) management in acute stroke. The control of cerebral blood flow (CBF) involves a myriad of complex pathways which are largely unaccounted for in stroke management. Due to its unique anatomy and physiology, the cerebrovascular circulation is often treated as a stand-alone system rather than an integral component of the cardiovascular system. In order to optimize the strategies for BP management in acute ischemic stroke, a critical reappraisal of the mechanisms involved in CBF control is needed. In this review, we highlight the important role of collateral circulation and re-examine the pathophysiology of CBF control, namely the determinants of cerebral perfusion pressure gradient and resistance, in the context of stroke. Finally, we summarize the state of our knowledge regarding cardiovascular and cerebrovascular interaction and explore some potential avenues for future research in ischemic stroke.
Collapse
Affiliation(s)
- Jui-Lin Fan
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec City, Canada.,Research Center of the Institut universitaire de cardiologie et de pneumologie de Québec, Québec City, Canada
| | - Caroline A Rickards
- Department of Physiology & Anatomy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Ricardo C Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil.,Neurology Department, Hospital Nove de Julho, São Paulo, Brazil
| | - Nathalie Nasr
- Department of Neurology, Toulouse University Hospital, NSERM UMR 1297, Toulouse, France
| | - Fiona D McBryde
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - James P Fisher
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Yu-Chieh Tzeng
- Wellington Medical Technology Group, Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand.,Department of Surgery & Anaesthesia, Centre for Translational Physiology, University of Otago, Wellington, New Zealand
| |
Collapse
|
31
|
Gil Y, Lee MJ, Cho S, Chung C. Effect of caffeine and caffeine cessation on cerebrovascular reactivity in patients with migraine. Headache 2022; 62:169-175. [DOI: 10.1111/head.14263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 11/23/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Young‐Eun Gil
- Department of Neurology Ajou University School of Medicine, Ajou University Medical Center Suwon South Korea
| | - Mi Ji Lee
- Department of Neurology Neuroscience Center Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Soohyun Cho
- Department of Neurology Uijeongbu Eulji Medical Center Eulji University School of Medicine Uijeongbu Korea
| | - Chin‐Sang Chung
- Department of Neurology Neuroscience Center Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| |
Collapse
|
32
|
Liu LD, Duricka DL. Stellate ganglion block reduces symptoms of Long COVID: A case series. J Neuroimmunol 2022; 362:577784. [PMID: 34922127 PMCID: PMC8653406 DOI: 10.1016/j.jneuroim.2021.577784] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/26/2021] [Accepted: 12/04/2021] [Indexed: 12/30/2022]
Abstract
After recovering from COVID-19, a significant proportion of symptomatic and asymptomatic individuals develop Long COVID. Fatigue, orthostatic intolerance, brain fog, anosmia, and ageusia/dysgeusia in Long COVID resemble "sickness behavior," the autonomic nervous system response to pro-inflammatory cytokines (Dantzer et al., 2008). Aberrant network adaptation to sympathetic/parasympathetic imbalance is expected to produce long-standing dysautonomia. Cervical sympathetic chain activity can be blocked with local anesthetic, allowing the regional autonomic nervous system to "reboot." In this case series, we successfully treated two Long COVID patients using stellate ganglion block, implicating dysautonomia in the pathophysiology of Long COVID and suggesting a novel treatment.
Collapse
|
33
|
Koep JL, Taylor CE, Coombes JS, Bond B, Ainslie PN, Bailey TG. Autonomic control of cerebral blood flow: fundamental comparisons between peripheral and cerebrovascular circulations in humans. J Physiol 2021; 600:15-39. [PMID: 34842285 DOI: 10.1113/jp281058] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/25/2021] [Indexed: 01/12/2023] Open
Abstract
Understanding the contribution of the autonomic nervous system to cerebral blood flow (CBF) control is challenging, and interpretations are unclear. The identification of calcium channels and adrenoreceptors within cerebral vessels has led to common misconceptions that the function of these receptors and actions mirror those of the peripheral vasculature. This review outlines the fundamental differences and complex actions of cerebral autonomic activation compared with the peripheral circulation. Anatomical differences, including the closed nature of the cerebrovasculature, and differential adrenoreceptor subtypes, density, distribution and sensitivity, provide evidence that measures on peripheral sympathetic nerve activity cannot be extrapolated to the cerebrovasculature. Cerebral sympathetic nerve activity seems to act opposingly to the peripheral circulation, mediated at least in part by changes in intracranial pressure and cerebral blood volume. Additionally, heterogeneity in cerebral adrenoreceptor distribution highlights region-specific autonomic regulation of CBF. Compensatory chemo- and autoregulatory responses throughout the cerebral circulation, and interactions with parasympathetic nerve activity are unique features to the cerebral circulation. This crosstalk between sympathetic and parasympathetic reflexes acts to ensure adequate perfusion of CBF to rising and falling perfusion pressures, optimizing delivery of oxygen and nutrients to the brain, while attempting to maintain blood volume and intracranial pressure. Herein, we highlight the distinct similarities and differences between autonomic control of cerebral and peripheral blood flow, and the regional specificity of sympathetic and parasympathetic regulation within the cerebrovasculature. Future research directions are outlined with the goal to further our understanding of autonomic control of CBF in humans.
Collapse
Affiliation(s)
- Jodie L Koep
- Physiology and Ultrasound Laboratory in Science and Exercise, Centre for Research on Exercise, Physical Activity and Health, School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia.,Children's Health and Exercise Research Centre, Sport and Health Sciences, College of Life and Environmental Sciences, University of Exeter, Exeter, UK
| | - Chloe E Taylor
- School of Health Sciences, Western Sydney University, Sydney, Australia
| | - Jeff S Coombes
- Physiology and Ultrasound Laboratory in Science and Exercise, Centre for Research on Exercise, Physical Activity and Health, School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Bert Bond
- Children's Health and Exercise Research Centre, Sport and Health Sciences, College of Life and Environmental Sciences, University of Exeter, Exeter, UK
| | - Philip N Ainslie
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia - Okanagan, Kelowna, British Columbia, Canada
| | - Tom G Bailey
- Physiology and Ultrasound Laboratory in Science and Exercise, Centre for Research on Exercise, Physical Activity and Health, School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia.,School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, Queensland, Australia
| |
Collapse
|
34
|
Claassen JAHR, Thijssen DHJ, Panerai RB, Faraci FM. Regulation of cerebral blood flow in humans: physiology and clinical implications of autoregulation. Physiol Rev 2021; 101:1487-1559. [PMID: 33769101 PMCID: PMC8576366 DOI: 10.1152/physrev.00022.2020] [Citation(s) in RCA: 292] [Impact Index Per Article: 97.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Brain function critically depends on a close matching between metabolic demands, appropriate delivery of oxygen and nutrients, and removal of cellular waste. This matching requires continuous regulation of cerebral blood flow (CBF), which can be categorized into four broad topics: 1) autoregulation, which describes the response of the cerebrovasculature to changes in perfusion pressure; 2) vascular reactivity to vasoactive stimuli [including carbon dioxide (CO2)]; 3) neurovascular coupling (NVC), i.e., the CBF response to local changes in neural activity (often standardized cognitive stimuli in humans); and 4) endothelium-dependent responses. This review focuses primarily on autoregulation and its clinical implications. To place autoregulation in a more precise context, and to better understand integrated approaches in the cerebral circulation, we also briefly address reactivity to CO2 and NVC. In addition to our focus on effects of perfusion pressure (or blood pressure), we describe the impact of select stimuli on regulation of CBF (i.e., arterial blood gases, cerebral metabolism, neural mechanisms, and specific vascular cells), the interrelationships between these stimuli, and implications for regulation of CBF at the level of large arteries and the microcirculation. We review clinical implications of autoregulation in aging, hypertension, stroke, mild cognitive impairment, anesthesia, and dementias. Finally, we discuss autoregulation in the context of common daily physiological challenges, including changes in posture (e.g., orthostatic hypotension, syncope) and physical activity.
Collapse
Affiliation(s)
- Jurgen A H R Claassen
- Department of Geriatrics, Radboud University Medical Center, Donders Institute for Brain, Cognition, and Behaviour, Nijmegen, The Netherlands
| | - Dick H J Thijssen
- Department of Physiology, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- >National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Frank M Faraci
- Departments of Internal Medicine, Neuroscience, and Pharmacology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| |
Collapse
|
35
|
Hasegawa Y, Uchikawa H, Kajiwara S, Morioka M. Central sympathetic nerve activation in subarachnoid hemorrhage. J Neurochem 2021; 160:34-50. [PMID: 34525222 DOI: 10.1111/jnc.15511] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/04/2021] [Accepted: 09/07/2021] [Indexed: 12/12/2022]
Abstract
Subarachnoid hemorrhage (SAH) is a life-threatening condition, and although its two main complications-cerebral vasospasm (CVS)/delayed cerebral ischemia (DCI) and early brain injury (EBI)-have been widely studied, prognosis has not improved over time. The sympathetic nerve (SN) system is important for the regulation of cardiovascular function and is closely associated with cerebral vessels and the regulation of cerebral blood flow and cerebrovascular function; thus, excessive SN activation leads to a rapid breakdown of homeostasis in the brain. In the hyperacute phase, patients with SAH can experience possibly lethal conditions that are thought to be associated with SN activation (catecholamine surge)-related arrhythmia, neurogenic pulmonary edema, and irreversible injury to the hypothalamus and brainstem. Although the role of the SN system in SAH has long been investigated and considerable evidence has been collected, the exact pathophysiology remains undetermined, mainly because the relationships between the SN system and SAH are complicated, and many SN-modulating factors are involved. Thus, research concerning these relationships needs to explore novel findings that correlate with the relevant concepts based on past reliable evidence. Here, we explore the role of the central SN (CSN) system in SAH pathophysiology and provide a comprehensive review of the functional CSN network; brain injury in hyperacute phase involving the CSN system; pathophysiological overlap between the CSN system and the two major SAH complications, CVS/DCI and EBI; CSN-modulating factors; and SAH-related extracerebral organ injury. Further studies are warranted to determine the specific roles of the CSN system in the brain injuries associated with SAH.
Collapse
Affiliation(s)
- Yu Hasegawa
- Department of Pharmaceutical Science, School of Pharmacy at Fukuoka, International University of Health and Welfare, Okawa, Fukuoka, Japan.,Department of Neurosurgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Hiroki Uchikawa
- Department of Neurosurgery, Kumamoto University School of Medicine, Kumamoto, Kumamoto, Japan
| | - Sosho Kajiwara
- Department of Neurosurgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| |
Collapse
|
36
|
Toro C, Temkin N, Barber J, Manley G, Jain S, Ohnuma T, Komisarow J, Foreman B, Korley FK, Vavilala MS, Laskowitz DT, Mathew JP, Hernandez A, Sampson J, James ML, Goldstein BA, Markowitz AJ, Krishnamoorthy V. Association of Vasopressor Choice with Clinical and Functional Outcomes Following Moderate to Severe Traumatic Brain Injury: A TRACK-TBI Study. Neurocrit Care 2021; 36:180-191. [PMID: 34341913 DOI: 10.1007/s12028-021-01280-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/17/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early hypotension following moderate to severe traumatic brain injury (TBI) is associated with increased mortality and poor long-term outcomes. Current guidelines suggest the use of intravenous vasopressors to support blood pressure following TBI; however, guidelines do not specify vasopressor type, resulting in variation in clinical practice. Minimal data are available to guide clinicians on optimal early vasopressor choice to support blood pressure following TBI. Therefore, we conducted a multicenter study to examine initial vasopressor choice for the support of blood pressure following TBI and its association with clinical and functional outcomes after injury. METHODS We conducted a retrospective cohort study of patients enrolled in the transforming research and clinical knowledge in traumatic brain injury (TRACK-TBI) study, an 18-center prospective cohort study of patients with TBI evaluated in participating level I trauma centers. We examined adults with moderate to severe TBI (defined as Glasgow Coma Scale score < 13) who were admitted to the intensive care unit and received an intravenous vasopressor within 48 h of admission. The primary exposure was initial vasopressor choice (phenylephrine versus norepinephrine), and the primary outcome was 6-month Glasgow Outcomes Scale Extended (GOSE), with the following secondary outcomes: length of hospital stay, length of intensive care unit stay, in-hospital mortality, new requirement for dialysis, and 6-month Disability Rating Scale. Regression analysis was used to assess differences in outcomes between patients exposed to norepinephrine versus phenylephrine, with propensity weighting to address selection bias due to the nonrandom allocation of the treatment groups and patient dropout. RESULTS The final study sample included 156 patients, of whom 79 (51%) received norepinephrine, 69 (44%) received phenylephrine, and 8 (5%) received an alternate drug as their initial vasopressor. 121 (77%) of patients were men, with a mean age of 43.1 years. Of patients receiving norepinephrine as their initial vasopressor, 32% had a favorable outcome (GOSE 5-8), whereas 40% of patients receiving phenylephrine as their initial vasopressor had a favorable outcome. Compared with phenylephrine, exposure to norepinephrine was not significantly associated with improved 6-month GOSE (weighted odds ratio 1.40, 95% confidence interval 0.66-2.96, p = 0.37) or any secondary outcome. CONCLUSIONS The majority of patients with moderate to severe TBI received either phenylephrine or norepinephrine as first-line agents for blood pressure support following brain injury. Initial choice of norepinephrine, compared with phenylephrine, was not associated with improved clinical or functional outcomes.
Collapse
Affiliation(s)
- Camilo Toro
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Nancy Temkin
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Jason Barber
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Geoffrey Manley
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA, USA
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, CA, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | | | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Frederick K Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Daniel T Laskowitz
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | | | - John Sampson
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Michael L James
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
| | - Benjamin A Goldstein
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Amy J Markowitz
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Durham, NC, USA.
- Department of Anesthesiology, Duke University, Durham, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
| |
Collapse
|
37
|
The Regional Cerebral Oxygen Saturation Effect of Inotropes/Vasopressors Administered to Treat Intraoperative Hypotension: A Bayesian Network Meta-analysis. J Neurosurg Anesthesiol 2021; 35:31-40. [PMID: 34116546 PMCID: PMC9142214 DOI: 10.1097/ana.0000000000000783] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 05/05/2021] [Indexed: 02/07/2023]
Abstract
One of the main concerns of intraoperative hypotension is adequacy of cerebral perfusion, as cerebral blood flow decreases passively when mean arterial pressure falls below the lower limit of cerebral autoregulation. Treatment of intraoperative hypotension includes administration of drugs, such as inotropes and vasopressors, which have different pharmacological effects on cerebral hemodynamics; there is no consensus on the preferred drug to use. We performed a network meta-analysis (NMA) to pool and analyze data comparing the effect on cerebral oxygen saturation (ScO 2 ) measured by cerebral oximetry of various inotropes/vasopressors used to treat intraoperative hypotension. We searched randomized control trials in Embase, Ovid Medline, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science. We included studies that enrolled adult patients undergoing surgery under general/spinal anesthesia that compared at least 2 inotropes/vasopressors to treat hypotension. We reviewed 51 full-text manuscripts and included 9 randomized controlled trials in our study. The primary outcome was change in ScO 2 . Our results showed the likelihood that dopamine, ephedrine, and norepinephrine had the lowest probability of decreasing ScO 2 . The suggested rank order to maintain ScO 2 , from higher to lower, was dopamine <ephedrine <norepinephrine <phenylephrine. Drugs in the lower rank order, like phenylephrine, produce higher reductions in ScO 2 . Compared with dopamine, the mean difference (95% credible interval) of ScO 2 reduction was: ephedrine -3.19 (-15.74, 8.82), norepinephrine -4.44 (-18.23, 9.63) and phenylephrine -6.93 (-18.31, 4.47). The results of our NMA suggest that dopamine and ephedrine are more likely to preserve ScO 2 , followed by norepinephrine. Compared with the other inotropes/vasopressors, phenylephrine decreased ScO 2 . Because of the inherent imprecision of direct/indirect comparisons, the rank orders are possibilities, not absolute ranks. Therefore the results of this NMA should be interpreted with caution.
Collapse
|
38
|
Larson S, Anderson L, Thomson S. Effect of phenylephrine on cerebral oxygen saturation and cardiac output in adults when used to treat intraoperative hypotension: a systematic review. JBI Evid Synth 2021; 19:34-58. [PMID: 32941358 DOI: 10.11124/jbisrir-d-19-00352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The objective of this review was to examine the effect of phenylephrine on cerebral oxygen saturation, cardiac output, and middle cerebral artery blood flow velocity when used to treat intraoperative hypotension. INTRODUCTION While the etiology of postoperative cognitive dysfunction in adults following surgery is likely multifactorial, intraoperative cerebral hypoperfusion is a commonly proposed mechanism. Research evidence and expert opinion are emerging that suggest phenylephrine adversely affects cerebral oxygen saturation and may also adversely affect cerebral perfusion via a reduction in cardiac output or cerebral vascular vasoconstriction. The administration of phenylephrine to treat intraoperative hypotension is common anesthesia practice, despite a lack of evidence to show it improves cerebral perfusion. Therefore, a systematic review of the effect of phenylephrine on cerebral hemodynamics has significant implications for anesthesia practice and future research. INCLUSION CRITERIA Studies of adults 18 years and over undergoing elective, non-neurosurgical procedures involving anesthesia were included. In these studies, participants received phenylephrine to treat intraoperative hypotension. The effect of phenylephrine on cerebral oxygen saturation, cardiac output, or middle cerebral artery blood flow velocity was measured. METHODS Key information sources searched included MEDLINE (Ovid), Embase, CINAHL (EBSCO), and Google Scholar. The scope of the search was limited to English-language studies published from 1999 through 2017. The recommended JBI approach to critical appraisal, study selection, data extraction, and data synthesis were used. RESULTS This systematic review found that phenylephrine consistently decreased cerebral oxygen saturation values despite simultaneously increasing mean arterial pressure to normal range. Results also found that ephedrine and dopamine were superior to phenylephrine in maintaining or increasing values. Phenylephrine was found to be similar to vasopressin in the extent to which both decreased cerebral oxygen saturation values. Results also showed that phenylephrine resulted in statistically significant declines in cardiac output, or failed to improve abnormally low preintervention values. The effect of phenylephrine on middle cerebral artery blood flow velocity was only measured in one study and showed that phenylephrine increased flow velocity by about 20%. Statistical pooling of the study results was not possible due to the gross variation in how the intervention was administered and how effect was measured. CONCLUSIONS This review found that phenylephrine administration resulted in declines in cerebral oxygen saturation and cardiac output. However, the research studies were ineffective in informing phenylephrine's mechanism of action or its impact on postoperative cognitive function. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO (CRD42018100740).
Collapse
Affiliation(s)
- Sandra Larson
- Rosalind Franklin University of Medicine and Science: A JBI Affiliated Group, Chicago, IL, USA
| | | | | |
Collapse
|
39
|
Stöhr EJ, Ji R, Akiyama K, Mondellini G, Braghieri L, Pinsino A, Cockcroft JR, Yuzefpolskaya M, Amlani A, Topkara VK, Takayama H, Naka Y, Uriel N, Takeda K, Colombo PC, McDonnell BJ, Willey JZ. Cerebral vasoreactivity in HeartMate 3 patients. J Heart Lung Transplant 2021; 40:786-793. [PMID: 34134913 DOI: 10.1016/j.healun.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 05/04/2021] [Accepted: 05/09/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND While rates of stroke have declined with the HeartMate3 (HM3) continuous- flow (CF) left ventricular assist device (LVAD), the impact of non-pulsatile flow and artificial pulse physiology on cerebrovascular function is not known. We hypothesized that improved hemodynamics and artificial pulse physiology of HM3 patients would augment cerebrovascular metabolic reactivity (CVR) compared with HeartMate II (HMII) CF-LVAD and heart failure (HF) patients. METHODS Mean, peak systolic and diastolic flow velocities (MFV, PSV, MinFV, respectively) and cerebral pulsatility index were determined in the middle cerebral artery (MCA) before and after a 30 sec breath-hold challenge in 90 participants: 24 healthy controls; 30 HF, 15 HMII, and 21 HM3 patients. RESULTS In HM3 patients, breath-holding increased MFV (Δ8 ± 10 cm/sec, p < .0001 vs baseline) to levels similar to HF patients (Δ9 ± 8 cm/sec, p > .05), higher than HMII patients (Δ2 ± 8 cm/sec, p < .01) but lower than healthy controls (Δ13 ± 7 cm/sec, p < .05). CF-LVAD altered the proportion of systolic and diastolic flow responses as reflected by a differential cerebral pulsatility index (p = .03). Baseline MFV was not related to CVR (r2 = 0.0008, p = .81). However, CF-LVAD pump speed was strongly inversely associated with CVR in HM II (r2 = 0.51, p = .003) but not HM3 patients (r2 = 0.01, p = .65). CONCLUSIONS Compared with HMII, HM3 patients have a significantly improved CVR. However, CVR remains lower in HM3 and HF patients than in healthy controls, therefore suggesting that changes in cerebral hemodynamics are not reversed by CF-LVAD therapy. Further research on the mechanisms and the long-term impact of altered cerebral hemodynamics in this unique patient population are warranted.
Collapse
Affiliation(s)
- Eric J Stöhr
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom; Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York.
| | - Ruiping Ji
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Koichi Akiyama
- Department of Medicine, Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York City, New York; Department of Anesthesia, Yodogawa Christian Hospital, Osaka City, Osaka, Japan
| | - Giulio Mondellini
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Lorenzo Braghieri
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Alberto Pinsino
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - John R Cockcroft
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom; Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Amrin Amlani
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Hiroo Takayama
- Department of Medicine, Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York City, New York
| | - Yoshifumi Naka
- Department of Medicine, Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York City, New York
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Koji Takeda
- Department of Medicine, Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York City, New York
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Barry J McDonnell
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom
| | - Joshua Z Willey
- Department of Neurology, Columbia University Irving Medical Center, New York City, New York
| |
Collapse
|
40
|
Cardiac Output: The Neglected Stepchild of the Cerebral Blood Flow Physiology Family. J Neurosurg Anesthesiol 2021; 32:93-94. [PMID: 31972625 DOI: 10.1097/ana.0000000000000677] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
41
|
Davis J, Ozcan MS, Kamdar JK, Shoaib M. Stellate ganglion block used to treat reversible cerebral vasoconstriction syndrome. Reg Anesth Pain Med 2021; 46:732-734. [PMID: 33875578 DOI: 10.1136/rapm-2021-102675] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND We present a case report of a patient who developed severe reversible cerebral vasoconstriction syndrome, which was worsening despite typical interventional and supportive care. We administered a stellate ganglion block (SGB) and monitored the vasospasm with transcranial Doppler measurements. CASE REPORT A 25-year-old woman was admitted with recurrent headaches and neurological symptoms, which angiography showed to be caused by diffuse, multifocal, segmental narrowing of the cerebral arteries leading to severe ischemia in multiple regions. Typical treatment was initiated with arterial verapamil followed by supportive critical care, including nimodipine, intravenous fluids, permissive hypertension, and analgesia. Vasospasm was monitored daily via transcranial Doppler ultrasound (TCD). After symptoms and monitoring suggested worsening vasospasm, an SGB was administered under ultrasound guidance. Block success was confirmed via pupillometry, and repeat TCD showed improved flow through the cerebral vasculature. Improvement in vascular flow was accompanied by a gradual reduction in acute neurological symptoms, with the patient reporting no headaches the following morning. CONCLUSIONS For patients with reversible cerebral vasoconstriction syndrome who develop severe signs or symptoms despite typical treatment, sympathetic blockade may be a possible rescue therapy. This may extend to other causes of severe vasospasm as well, and further study is needed to determine if the SGB should be included in routine or rescue therapy.
Collapse
Affiliation(s)
- Jeffrey Davis
- Anesthesiology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Mehmet S Ozcan
- Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jay K Kamdar
- Anesthesiology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Maria Shoaib
- Neurology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| |
Collapse
|
42
|
Panerai RB, Batterham A, Robinson TG, Haunton VJ. Determinants of cerebral blood flow velocity change during squat-stand maneuvers. Am J Physiol Regul Integr Comp Physiol 2021; 320:R452-R466. [PMID: 33533312 DOI: 10.1152/ajpregu.00291.2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The large changes in mean arterial blood pressure (MABP) and cerebral blood flow velocity (CBFV) induced by squat-stand maneuvers (SSM) make this approach particularly suited for studying dynamic cerebral autoregulation (CA). However, the role of other systemic determinants of CBFV has not been described and could provide alternative physiological interpretations of SSM results. In 32 healthy subjects (16 female), continuous recordings of MABP (Finometer), bilateral CBFV (transcranial Doppler, MCA), end-tidal CO2 (EtCO2; capnography), and heart rate (HR; electrocardiogram) were performed for 5 min standing at rest, and during 15 SSM at the frequency of 0.05 Hz. A time-domain, multivariate dynamic model estimated the CBFV variance explained by different inputs, corresponding to significant contributions from MABP (P < 0.00001), EtCO2 (P < 0.0001), and HR (P = 0.041). The autoregulation index (ARI; range 0-9) was estimated from the CBFV response to a step change in MABP. At rest, ARI values (typically 5.7) were independent of the number of model inputs, but during SSM, ARI was reduced compared with baseline (P < 0.0001), and the three input model yielded lower values for the right and left MCA (3.4 ± 1.2, 3.1 ± 1.3) when compared with the single-input MABP-CBFV model (4.1 ± 1.1, 3.9 ± 1.0; P < 0.0001). The high coherence of the MABP-CBFV transfer function at 0.05 Hz (typically 0.98) was considerably reduced (around 0.71-0.73; P < 0.0001) when the contribution of CBFV covariates was taken into account. Not taking into consideration other determinants of CBFV, in addition to MABP, could be misleading and introduce biases in physiological and clinical studies.
Collapse
Affiliation(s)
- Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Angus Batterham
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Victoria J Haunton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| |
Collapse
|
43
|
Cerritelli F, Chiacchiaretta P, Gambi F, Saggini R, Perrucci MG, Ferretti A. Osteopathy modulates brain-heart interaction in chronic pain patients: an ASL study. Sci Rep 2021; 11:4556. [PMID: 33633195 PMCID: PMC7907192 DOI: 10.1038/s41598-021-83893-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 02/09/2021] [Indexed: 01/31/2023] Open
Abstract
In this study we used a combination of measures including regional cerebral blood flow (rCBF) and heart rate variability (HRV) to investigate brain-heart correlates of longitudinal baseline changes of chronic low back pain (cLBP) after osteopathic manipulative treatment (OMT). Thirty-two right-handed patients were randomised and divided into 4 weekly session of OMT (N = 16) or Sham (N = 16). Participants aged 42.3 ± 7.3 (M/F: 20/12) with cLBP (duration: 14.6 ± 8.0 m). At the end of the study, patients receiving OMT showed decreased baseline rCBF within several regions belonging to the pain matrix (left posterior insula, left anterior cingulate cortex, left thalamus), sensory regions (left superior parietal lobe), middle frontal lobe and left cuneus. Conversely, rCBF was increased in right anterior insula, bilateral striatum, left posterior cingulate cortex, right prefrontal cortex, left cerebellum and right ventroposterior lateral thalamus in the OMT group as compared with Sham. OMT showed a statistically significant negative correlation between baseline High Frequency HRV changes and rCBF changes at T2 in the left posterior insula and bilateral lentiform nucleus. The same brain regions showed a positive correlation between rCBF changes and Low Frequency HRV baseline changes at T2. These findings suggest that OMT can play a significant role in regulating brain-heart interaction mechanisms.
Collapse
Affiliation(s)
- Francesco Cerritelli
- grid.412451.70000 0001 2181 4941Department of Neuroscience, Imaging and Clinical Sciences, “G. D’Annunzio” University of Chieti-Pescara, Via dei Vestini, 33, Chieti Scalo, Italy ,Clinical-Based Human Research Department, Foundation C.O.ME. Collaboration, Pescara, Italy
| | - Piero Chiacchiaretta
- grid.412451.70000 0001 2181 4941Department of Neuroscience, Imaging and Clinical Sciences, “G. D’Annunzio” University of Chieti-Pescara, Via dei Vestini, 33, Chieti Scalo, Italy ,grid.412451.70000 0001 2181 4941ITAB-Institute for Advanced Biomedical Technologies, “G. D’Annunzio” University of Chieti-Pescara, Chieti, Italy
| | - Francesco Gambi
- grid.412451.70000 0001 2181 4941Department of Neuroscience, Imaging and Clinical Sciences, “G. D’Annunzio” University of Chieti-Pescara, Via dei Vestini, 33, Chieti Scalo, Italy ,grid.412451.70000 0001 2181 4941ITAB-Institute for Advanced Biomedical Technologies, “G. D’Annunzio” University of Chieti-Pescara, Chieti, Italy
| | - Raoul Saggini
- grid.412451.70000 0001 2181 4941School of Specialty in Physical and Rehabilitation Medicine, “G. D’Annunzio” University of Chieti-Pescara, Chieti, Italy
| | - Mauro Gianni Perrucci
- grid.412451.70000 0001 2181 4941Department of Neuroscience, Imaging and Clinical Sciences, “G. D’Annunzio” University of Chieti-Pescara, Via dei Vestini, 33, Chieti Scalo, Italy ,grid.412451.70000 0001 2181 4941ITAB-Institute for Advanced Biomedical Technologies, “G. D’Annunzio” University of Chieti-Pescara, Chieti, Italy
| | - Antonio Ferretti
- grid.412451.70000 0001 2181 4941Department of Neuroscience, Imaging and Clinical Sciences, “G. D’Annunzio” University of Chieti-Pescara, Via dei Vestini, 33, Chieti Scalo, Italy ,grid.412451.70000 0001 2181 4941ITAB-Institute for Advanced Biomedical Technologies, “G. D’Annunzio” University of Chieti-Pescara, Chieti, Italy
| |
Collapse
|
44
|
Salminen A. Hypoperfusion is a potential inducer of immunosuppressive network in Alzheimer's disease. Neurochem Int 2020; 142:104919. [PMID: 33242538 DOI: 10.1016/j.neuint.2020.104919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/12/2020] [Accepted: 11/19/2020] [Indexed: 12/12/2022]
Abstract
Alzheimer's disease (AD) is a progressive neurodegenerative disease which causes a non-reversible cognitive impairment and dementia. The primary cause of late-onset AD remains unknown although its pathology was discovered over a century ago. Recently, the vascular hypothesis of AD has received backing from evidence emerging from neuroimaging studies which have revealed the presence of a significant hypoperfusion in the brain regions vulnerable to AD pathology. In fact, hypoxia can explain many of the pathological changes evident in AD pathology, e.g. the deposition of β-amyloid plaques and chronic low-grade inflammation. Hypoxia-inducible factor-1α (HIF-1α) stimulates inflammatory responses and modulates both innate and adaptive immunity. It is known that hypoxia-induced inflammation evokes compensatory anti-inflammatory response involving tissue-resident microglia/macrophages and infiltrated immune cells. Hypoxia/HIF-1α induce immunosuppression by (i) increasing the expression of immunosuppressive genes, (ii) stimulating adenosinergic signaling, (iii) enhancing aerobic glycolysis, i.e. lactate production, and (iv) augmenting the secretion of immunosuppressive exosomes. Interestingly, it seems that these common mechanisms are also involved in the pathogenesis of AD. In AD pathology, an enhanced immunosuppression appears, e.g. as a shift in microglia/macrophage phenotypes towards the anti-inflammatory M2 phenotype and an increase in the numbers of regulatory T cells (Treg). The augmented anti-inflammatory capacity promotes the resolution of acute inflammation but persistent inflammation has crucial effects not only on immune cells but also harmful responses to the homeostasis of AD brain. I will examine in detail the mechanisms of the hypoperfusion/hypoxia-induced immunosuppressive state in general and especially, in its association with AD pathogenesis. These immunological observations support the vascular hypothesis of AD pathology.
Collapse
Affiliation(s)
- Antero Salminen
- Department of Neurology, Institute of Clinical Medicine, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland.
| |
Collapse
|
45
|
Barnes JN, Charkoudian N. Integrative cardiovascular control in women: Regulation of blood pressure, body temperature, and cerebrovascular responsiveness. FASEB J 2020; 35:e21143. [PMID: 33151577 DOI: 10.1096/fj.202001387r] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/21/2020] [Accepted: 10/13/2020] [Indexed: 12/14/2022]
Abstract
Over the past several decades, it has become increasingly clear that women have distinct cardiovascular profiles compared to men. In this review, our goal is to provide an overview of the literature regarding the influences of female sex and reproductive hormones (primarily estradiol) on mechanisms of cardiovascular control relevant to regulation of blood pressure, body temperature, and cerebral blood flow. Young women tend to have lower resting blood pressure compared with men. This sex difference is reversed at menopause, when women develop higher sympathetic nerve activity and the risk of systemic hypertension increases sharply as postmenopausal women age. Vascular responses to thermal stress, including cutaneous vasodilation and vasoconstriction, are also affected by reproductive hormones in women, where estradiol appears to promote vasodilation and heat dissipation. The influence of reproductive hormones on cerebral blood flow and sex differences in the ability of the cerebral vasculature to increase its blood flow (cerebrovascular reactivity) are relatively new areas of investigation. Sex and hormonal influences on integrative blood flow regulation have further implications during challenges to physiological homeostasis, including exercise. We propose that increasing awareness of these sex-specific mechanisms is important for optimizing health care and promotion of wellness in women across the life span.
Collapse
Affiliation(s)
- Jill N Barnes
- Bruno Balke Biodynamics Laboratory, Department of Kinesiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Nisha Charkoudian
- US Army Research Institute of Environmental Medicine, Natick, MA, USA
| |
Collapse
|
46
|
Ashley JD, Shelley JH, Sun J, Song J, Trent JA, Ambrosio LD, Larson DJ, Larson RD, Yabluchanskiy A, Kellawan JM. Cerebrovascular responses to graded exercise in young healthy males and females. Physiol Rep 2020; 8:e14622. [PMID: 33112497 PMCID: PMC7592493 DOI: 10.14814/phy2.14622] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 10/04/2020] [Indexed: 01/06/2023] Open
Abstract
Although systemic sex-specific differences in cardiovascular responses to exercise are well established, the comparison of sex-specific cerebrovascular responses to exercise has gone under-investigated especially, during high intensity exercise. Therefore, our purpose was to compare cerebrovascular responses in males and females throughout a graded exercise test (GXT). Twenty-six participants (13 Females and 13 Males, 24 ± 4 yrs.) completed a GXT on a recumbent cycle ergometer consisting of 3-min stages. Each sex completed 50W, 75W, 100W stages. Thereafter, power output increased 30W/stage for females and 40W/stage for males until participants were unable to maintain 60-80 RPM. The final stage completed by the participant was considered maximum workload(Wmax ). Respiratory gases (End-tidal CO2 , EtCO2 ), middle cerebral artery blood velocity (MCAv), heart rate (HR), non-invasive mean arterial pressure (MAP), cardiac output (CO), and stroke volume (SV) were continuously recorded on a breath-by-breath or beat-by-beat basis. Cerebral perfusion pressure, CPP = MAP (0. 7,355 distance from heart-level to doppler probe) and cerebral vascular conductance index, CVCi = MCAv/CPP 100mmHg were calculated. The change from baseline (Δ) in MCAv was similar between the sexes during the GXT (p = .091, ωp2 = 0.05). However, ΔCPP (p < .001, ωp2 = 0.25) was greater in males at intensities ≥ 80% Wmax and ΔCVCi (p = .005, ωp2 = 0.15) was greater in females at 100% Wmax . Δ End-tidal CO2 (ΔEtCO2 ) was not different between the sexes during exercise (p = .606, ωp2 = -0.03). These data suggest there are sex-specific differences in cerebrovascular control, and these differences may only be identifiable at high and severe intensity exercise.
Collapse
Affiliation(s)
- John D. Ashley
- Department of Health and Exercise ScienceHuman Circulation Research LaboratoryUniversity of OklahomaNormanOKUSA
| | - Joe H. Shelley
- Department of Health and Exercise ScienceHuman Circulation Research LaboratoryUniversity of OklahomaNormanOKUSA
| | - Jongjoo Sun
- Department of Health and Exercise ScienceHuman Circulation Research LaboratoryUniversity of OklahomaNormanOKUSA
| | - Jiwon Song
- Department of Health and Exercise ScienceHuman Circulation Research LaboratoryUniversity of OklahomaNormanOKUSA
| | - Jacob A. Trent
- Department of Health and Exercise ScienceHuman Circulation Research LaboratoryUniversity of OklahomaNormanOKUSA
| | - Luis D. Ambrosio
- Department of Health and Exercise ScienceHuman Circulation Research LaboratoryUniversity of OklahomaNormanOKUSA
| | - Daniel J. Larson
- Department of Health and Exercise Science, Sport, Health, and Exercise Data Analytics LaboratoryUniversity of OklahomaNormanOKUSA
| | - Rebecca D. Larson
- Department of Health and Exercise ScienceBody Composition and Physical Performance Research LaboratoryUniversity of OklahomaNormanOKUSA
| | - Andriy Yabluchanskiy
- Oklahoma Center for GeroscienceDepartment of Biochemistry and Molecular BiologyUniversity of Oklahoma Health Sciences CenterOklahoma CityOKUSA
| | - J. Mikhail Kellawan
- Department of Health and Exercise ScienceHuman Circulation Research LaboratoryUniversity of OklahomaNormanOKUSA
| |
Collapse
|
47
|
Effects of dobutamine and phenylephrine on cerebral perfusion in patients undergoing cerebral bypass surgery: a randomised crossover trial. Br J Anaesth 2020; 125:539-547. [PMID: 32718724 PMCID: PMC7565906 DOI: 10.1016/j.bja.2020.05.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/20/2020] [Accepted: 05/13/2020] [Indexed: 01/22/2023] Open
Abstract
Background Patients undergoing cerebral bypass surgery are prone to cerebral hypoperfusion. Currently, arterial blood pressure is often increased with vasopressors to prevent cerebral ischaemia. However, this might cause vasoconstriction of the graft and cerebral vasculature and decrease perfusion. We hypothesised that cardiac output, rather than arterial blood pressure, is essential for adequate perfusion and aimed to determine whether dobutamine administration resulted in greater graft perfusion than phenylephrine administration. Methods This randomised crossover study included 10 adult patients undergoing cerebral bypass surgery. Intraoperatively, patients randomly and sequentially received dobutamine to increase cardiac index or phenylephrine to increase mean arterial pressure (MAP). An increase of >10% in cardiac index or >10% in MAP was targeted, respectively. Before both interventions, a reference phase was implemented. The primary outcome was the absolute difference in graft flow between the reference and intervention phase. We compared the absolute flow difference between each intervention and constructed a random-effect linear regression model to explore treatment and carry-over effects. Results Graft flow increased with a median of 4.1 (inter-quartile range [IQR], 1.7–12.0] ml min−1) after dobutamine administration and 3.6 [IQR, 1.3–7.8] ml min−1 after phenylephrine administration (difference –0.6 ml min−1; 95% confidence interval [CI], –14.5 to 5.3; P=0.441). There was no treatment effect (0.9 ml min−1; 95% CI, 0.0–20.1; P=0.944) and no carry-over effect. Conclusions Both dobutamine and phenylephrine increased graft flow during cerebral bypass surgery, without a preference for one method over the other. Clinical trial registration Netherlands Trial Register, NL7077 (https://www.trialregister.nl/trial/7077).
Collapse
|
48
|
Saini HS, Shnoda M, Saini I, Sayre M, Tariq S. The Effects of Spinal Cord Stimulators on End Organ Perfusion: A Literature Review. Cureus 2020; 12:e7253. [PMID: 32292667 PMCID: PMC7152574 DOI: 10.7759/cureus.7253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Spinal cord stimulators (SCS) have been gaining momentum in the last decade as their role in the management of chronic pain has become more apparent. Our intention was to search, analyze and highlight the effects of spinal cord stimulators on end-organ perfusion. We also looked at vascular diseases of atherosclerotic and nonatherosclerotic nature by examining objective evidence of improved circulation, pain control, limb salvage, and quality of life. We paid specific attention to disease processes such as cerebral hypoperfusion, Chronic-Critical Limb Ischemia, Intractable Angina Pectoris (IAP), Raynaud’s syndrome and Thromboangiitis Obliterans. We performed a Medline database search for medical literature relevant to Spinal cord stimulators encompassing the years 1950 to 2019. Search terms included “Spinal cord stimulator,” plus one of the following search terms: vasculopathy, stroke, cerebral blood flow, angina pectoris, diabetic ulcers, chronic critical leg ischemia, thromboangiitis obliterans and peripheral vascular disease. We included both clinical and experimental human studies that investigated the effect of SCS’s on end-organ perfusion. We also investigated the pathophysiological mechanism of action of SCS’s on the vasculature. We found 497 articles of which 43 more relevant and impactful articles investigating the hemodynamic effects of SCS and its possible mechanism were selected. Animal studies were excluded from the literature review as they provided heterogeneity. In addition to reporting literature supporting the use of stimulators for currently FDA approved uses, we also actively looked for potential future uses. Spinal Cord stimulators showed improvement in cerebral blood flow, increased capillary recruitment, and better quality of life in many studies. Patients also had increased exercise capacity and a significant reduction in the use of narcotic drug use and daily anginal attacks in patients suffering from IAP.
Collapse
Affiliation(s)
| | - Mina Shnoda
- Internal Medicine, Allegheny Health Network, Pittsburgh, USA
| | - Ishveen Saini
- Internal Medicine, Lake Erie College of Osteopathic Medicine, Erie, USA
| | - Matthew Sayre
- Internal Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, USA
| | | |
Collapse
|
49
|
Marmarelis VZ, Shin DC, Oesterreich M, Mueller M. Quantification of dynamic cerebral autoregulation and CO 2 dynamic vasomotor reactivity impairment in essential hypertension. J Appl Physiol (1985) 2020; 128:397-409. [PMID: 31917625 DOI: 10.1152/japplphysiol.00620.2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The study of dynamic cerebral autoregulation (DCA) in essential hypertension has received considerable attention because of its clinical importance. Several studies have examined the dynamic relationship between spontaneous beat-to-beat arterial blood pressure data and contemporaneous cerebral blood flow velocity measurements (obtained via transcranial Doppler at the middle cerebral arteries) in the form of a linear input-output model using transfer function analysis. This analysis is more reliable when the contemporaneous effects of changes in blood CO2 tension are also taken into account, because of the significant effects of CO2 dynamic vasomotor reactivity (DVR) upon cerebral flow. In this article, we extract such input-output predictive models from spontaneous time series hemodynamic data of 24 patients with essential hypertension and 20 normotensive control subjects under resting conditions, using the novel methodology of principal dynamic modes (PDMs) that achieves improved estimation accuracy over previous methods for relatively short and noisy data. The obtained data-based models are subsequently used to compute indexes and markers that quantify DCA and DVR in each subject or patient and therefore can be used to assess the effects of essential hypertension. These model-based DCA and DVR indexes were properly defined to capture the observed effects of DCA and VR and found to be significantly different (P < 0.05) in the hypertensive patients. We also found significant differences between patients and control subjects in the relative contribution of three PDMs to the model output prediction, a finding that offers the prospect of identifying the physiological mechanisms affected by essential hypertension when the PDMs are interpreted in terms of specific physiological mechanisms.NEW & NOTEWORTHY This article presents novel model-based methodology for obtaining diagnostic indexes of dynamic cerebral autoregulation and dynamic vasomotor reactivity in hypertension.
Collapse
Affiliation(s)
- Vasilis Z Marmarelis
- Biomedical Simulations Resource Center, University of Southern California, Los Angeles, California
| | - Dae C Shin
- Biomedical Simulations Resource Center, University of Southern California, Los Angeles, California
| | | | - Martin Mueller
- Neurocenter, Luzerner Kantonsspital, Lucerne, Switzerland
| |
Collapse
|
50
|
Siegmueller C, Maties O, Gelb A. Anesthesia for meningioma surgery. HANDBOOK OF CLINICAL NEUROLOGY 2020; 169:285-295. [PMID: 32553296 DOI: 10.1016/b978-0-12-804280-9.00019-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Patients receiving treatment for a meningioma require anesthesia when undergoing open craniotomy and, in some cases, during preoperative tumor embolization and radiosurgery. Adequate anesthesia management is integral to patients' perioperative care, which consists of the three phases of preoperative assessment and optimization, intraoperative care, and postoperative recovery. The preoperative anesthesia evaluation focusses on the cardiorespiratory and neurologic systems, as well as the airway, but also extends to ensure the optimal treatment of significant comorbidities before surgical intervention. The goals of intraoperative care are maintenance of brain physiology, facilitating surgery, and correcting any adverse effects of surgery and underlying pathology to preserve general patient homeostasis. This requires adequate intraoperative patient monitoring, cardiorespiratory support, management of infusion therapy, and application of knowledge about the effects of anesthetic agents on brain physiology. The anesthesiologist's responsibilities for patient care extend well into the postoperative recovery period, with a focus on pain control, prevention, and treatment of postoperative nausea and vomiting (PONV), and, in some patients, intensive care therapy.
Collapse
Affiliation(s)
- Claas Siegmueller
- Department of Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, CA, United States.
| | - Oana Maties
- Department of Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, CA, United States
| | - Adrian Gelb
- Department of Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, CA, United States
| |
Collapse
|