Effects of stellate ganglion block on cerebrovascular vasodilation in elderly patients and patients with subarachnoid haemorrhage

Effect of Stellate Ganglion Block on Dysphagia and Cognitive Impairment in Cerebral Small Vessel Disease: A Randomized Controlled Study

BACKGROUNDS

Cerebral small vessel disease (CSVD) can potentially and frequently lead to dysphagia and cognitive impairment. Stellate ganglion block (SGB) can alleviate the symptoms by regulating neural pathways and improving cerebral blood circulation.

OBJECTIVES

This study aimed to explore the clinical effect of SGB on airway protection, dysphagia, cognitive impairment, and activities of daily living (ADL) in CSVD patients.

METHOD

This was a randomized controlled study conducted from February 2021 to May 2023, including 84 CSVD patients with dysphagia and cognitive impairment. The participants were randomly divided into the SGB group (n = 42) and the untreated group (n = 42). All received standard-of-care rehabilitation for 20 days. The SGB group received SGB once a day additionally. Assessments were conducted on Day 1 and Day 20, respectively. The Penetration-Aspiration Scale (PAS) was primary outcome. Modified Barium Swallow Impairment (MBSImp), Mini-Mental State Examination (MMSE), Modified Barthel Index (MBI) and adverse events were secondary outcomes. This study was registered at ClinicalTrials.gov, Identifier: NCT06176404.

RESULTS

There were two dropout cases in the untreated group. Time effect with statistical significance was observed in all assessments (p < .05). Group effect with statistical significance was observed in the PAS (z = -17.283, p < .001), MBSImp-Oral (z = -3.382, p = .001), MBSImp-Pharyngeal (z = -2.639, p = .008), MMSE (F = 7.450, p = .008), and MBI (F = 6.408, p = .013). During the treatment, there were no severe adverse events.

CONCLUSION

SGB can significantly and safely improve airway protection, dysphagia, cognitive function, and ADL in CSVD patients with dysphagia and cognitive impairment who received standard-of-care rehabilitation.

Cervical Ganglion Sympathectomy to Treat Cerebral Vasospasm in Subarachnoid Hemorrhage

Delayed cerebral ischemia (DCI) is still a significant cause of death and disability after aneurysmal subarachnoid hemorrhage. Cerebral vasospasm represents one of the most reported mechanisms associated with DCI. The management of DCI-related vasospasm remains a significant challenge for clinicians; induced hypertension, intraarterial vasodilators, and/or intracranial vessel angioplasty-particularly in refractory or recurrent cases-are the most used therapies. Because an essential role in the pathophysiology of cerebral vasospasm has been attributed to the adrenergic sympathetic nerves, a "sympatholytic" intervention, consisting of a temporary interruption of the sympathetic pathways using local anesthetics, has been advocated to minimize the vascular narrowing and reverse the consequences of cerebral vasospasm on tissue perfusion. In this review, we have analyzed the existing literature on the block of the cervical ganglions, particularly the stellate ganglion, in managing refractory cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. These findings could help clinicians to understand the potential role of such intervention and to develop future interventional trials in this setting.

Stellate ganglion block ameliorated central post-stroke pain with comorbid anxiety and depression through inhibiting HIF-1α/NLRP3 signaling following thalamic hemorrhagic stroke

BACKGROUND

Central post-stroke pain (CPSP) is an intractable and disabling central neuropathic pain that severely affects patients' lives, well-being, and socialization abilities. However, CPSP has been poorly studied mechanistically and its treatment remains challenging. Here, we used a rat model of CPSP induced by thalamic hemorrhage to investigate its underlying mechanisms and the effect of stellate ganglion block (SGB) on CPSP and emotional comorbidities.

METHODS

Thalamic hemorrhage was produced by injecting collagenase IV into the ventral-posterolateral nucleus (VPL) of the right thalamus. The up-and-down method with von Frey hairs was used to measure the mechanical allodynia. Behavioral tests were carried out to examine depressive and anxiety-like behaviors including the open field test (OFT), elevated plus maze test (EPMT), novelty-suppressed feeding test (NSFT), and forced swim test (FST). The peri-thalamic lesion tissues were collected for immunofluorescence, western blotting, and enzyme-linked immunosorbent assay (ELISA). Genetic knockdown of thalamic hypoxia-inducible factor-1α (HIF-1α) and NOD-like receptor thermal protein domain associated protein 3 (NLRP3) with microinjection of HIF-1α siRNA and NLRP3 siRNA into the VPL of thalamus were performed 3 days before collagenase injection into the same regions. Microinjection of lificiguat (YC-1) and MCC950 into the VPL of thalamus were administrated 30 min before the collagenase injection in order to inhibited HIF-1α and NLRP3 pharmacologically. Repetitive right SGB was performed daily for 5 days and laser speckle contrast imaging (LSCI) was conducted to examine cerebral blood flow.

RESULTS

Thalamic hemorrhage caused persistent mechanical allodynia and anxiety- and depression-like behaviors. Accompanying the persistent mechanical allodynia, the expression of HIF-1α and NLRP3, as well as the activities of microglia and astrocytes in the peri-thalamic lesion sites, were significantly increased. Genetic knockdown of thalamic HIF-1α and NLRP3 significantly attenuated mechanical allodynia and anxiety- and depression-like behaviors following thalamic hemorrhage. Further studies revealed that intra-thalamic injection of YC-1, or MCC950 significantly suppressed the activation of microglia and astrocytes, the release of pro-inflammatory cytokines, the upregulation of malondialdehyde (MDA), and the downregulation of superoxide dismutase (SOD), as well as mechanical allodynia and anxiety- and depression-like behaviors following thalamic hemorrhage. In addition, repetitive ipsilateral SGB significantly restored the upregulated HIF-1α/NLRP3 signaling and the hyperactivated microglia and astrocytes following thalamic hemorrhage. The enhanced expression of pro-inflammatory cytokines and the oxidative stress in the peri-thalamic lesion sites were also reversed by SGB. Moreover, LSCI showed that repetitive SGB significantly increased cerebral blood flow following thalamic hemorrhage. Most strikingly, SGB not only prevented, but also reversed the development of mechanical allodynia and anxiety- and depression-like behaviors induced by thalamic hemorrhage. However, pharmacological activation of thalamic HIF-1α and NLRP3 with specific agonists significantly eliminated the therapeutic effects of SGB on mechanical allodynia and anxiety- and depression-like behaviors following thalamic hemorrhage.

CONCLUSION

This study demonstrated for the first time that SGB could improve CPSP with comorbid anxiety and depression by increasing cerebral blood flow and inhibiting HIF-1α/NLRP3 inflammatory signaling.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of stellate ganglion injections guided by different approaches on hearing threshold in patients with sudden deafness

OBJECTIVE

The current study was conducted aimed at investigating the effect of stellate ganglion injection guided with different approaches on hearing threshold in patients harboring sudden deafness.

METHODS

There involved a total of 68 patients with sudden deafness in our study. The patients were randomly allocated into control group and study group, with 34 cases in each group. The control group and study group were respectively given conventional blind puncture block and ultrasound-guided stellate ganglion injection. The clinical efficacy, first puncture success rate, first block success rate, average block time, hearing threshold improvement value, vertigo disappearance time, hearing recovery time, hemorheological changes and complications of the two groups were compared.

RESULTS

The total effective rate of the study group was significantly higher than that of the control group (96.06 vs. 76.47%, P < 0.05). The first puncture success rate and the first block success rate of the study group were evidently higher than those of the control group, and the average block time of the study group was significantly shorter than that of the control group (P < 0.05). The improvement of hearing threshold in the study group was higher than that in the control group, and the time of vertigo disappearance and hearing recovery in the study group was shorter than that in the control group, with significant difference (P < 0.05). Before treatment, EAI, HCT and PV levels of the two groups were comparable (P > 0.05). After treatment, however, the levels of EAI, HCT and PV in the two groups were lower. Furthermore, the levels of EAI, HCT and PV in the study group were significantly lower compared with the control group (P < 0.05). The incidence of complications in the study group was significantly less than that in the control group (P < 0.05).

CONCLUSION

Ultrasound-guided stellate ganglion injection achieved beneficial effects in treating sudden deafness, which is available for wide clinical practice.

Autonomic control of cerebral blood flow: fundamental comparisons between peripheral and cerebrovascular circulations in humans

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.

Propofol improves brain injury induced by chronic cerebral hypoperfusion in rats

To study effect of propofol on cognitive dysfunction and brain injury in a rat model of chronic cerebral hypoperfusion. The bilateral carotid artery ligation (bilateral common carotid artery occlusion and BCCAO) to establish rat model of chronic cerebral hypoperfusion and randomly assigned to 4 groups (n = 10): sham-operation group treated with saline model group, propofol treatment model group, normal saline treatment, propofol treatment in the sham-operation group; continuous intraperitoneal injection of propofol and saline for 12 weeks. Morris water maze was used to evaluate the learning and memory ability of rats. Determination of central cholinergic and oxidative stress in brain tissue by spectrophotometry. Detection of inflammatory response in brain tissue by immunohistochemistry and ELISA method. Detection of neuronal loss in brain tissue by Nissl and TUNEL staining. Compared with the saline-treated model group, propofol in model group significantly increased the rat brain tissue SOD activity (p < .01) and GPX activity (p < .01), decreased the MDA levels (p < .01) and protein carbonyl compound levels (p < .01). The propofol treatment of model group rats hippocampal GFAP-immunoreactive satellite glial cells (p < .01) and immune Iba1-positive microglia cells (p < .01) area percent compared to saline-treated model group decreased significantly. The number of normal propofol treatment of model group rats hippocampus neuron than in physiological saline treatment model group rats was significantly increased (p < .01). Propofol can improve chronic cerebral hypoperfusion in rats induced by cognitive dysfunction and brain damage.

Effects of stellate ganglion block on early brain injury in patients with subarachnoid hemorrhage: a randomised control trial

Background

Subarachnoid hemorrhage (SAH) is a common neurosurgical emergency, and early brain injury (EBI) plays an important role in acute brain injury of SAH. Our objective is to investigate the effect of stellate ganglion block (SGB) on the clinical prognosis of patients with SAH (registration number ChiCTR2000030910).

Methods

A randomized controlled trial was conducted with 102 participants. Patients with SAH were assigned to the SGB or nSGB group. Patients in the SGB group received SGB four times (once every other day starting on the day of the surgery). In contrast, patients in the nSGB group only received standard care. Data were collected on the day before surgery (T0) and on the 1^st (T1), 3^rd (T2) and 7^th day (T3) after surgery. The primary outcomes included EBI markers (including IL-1β, IL-6, TNF-α, ET-1, NPY, NSE and S100β), the mean cerebral blood flow velocity of the middle cerebral artery (Vm-MCA) and the basilar artery (Vm-BA). All cases were followed up for 6 months after surgery.

Results

The levels of the EBI markers in both groups were higher at T1–T3 than at T0 (P<0.05), and the Vm-MCA and Vm-BA were also increased at the same times. However, the levels of the EBI markers were lower in the SGB group than in the nSGB group (P<0.05), and the increases of Vm-MCA and Vm-BA were also lower (P<0.05). The prognosis score and neurological deficit were better in the SGB group than in the nSGB group (P<0.05).

Conclusions

SGB can improve the prognosis of SAH patients by inhibiting the inflammatory response during EBI and by reducing endothelial dysfunction and relieving CVS.

Trial registration

Clinical trial number: ChiCTR2000030910; Registry URL: Chinese Clinical Trial Registry; Principal investigator's name: Ying Nie; Date of Trial registration: March, 2020 (retrospectively registered).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-020-01215-3.

Decrease of blood flow velocity in the middle cerebral artery after stellate ganglion block following aneurysmal subarachnoid hemorrhage: a potential vasospasm treatment?

OBJECTIVE

Cerebral vasospasm (CV) is a delayed, sustained contraction of the cerebral arteries that tends to occur 3-14 days after aneurysmal subarachnoid hemorrhage (aSAH) from a ruptured aneurysm. Vasospasm potentially leads to delayed cerebral ischemia, and despite medical treatment, 1 of 3 patients suffer a persistent neurological deficit. Bedside transcranial Doppler (TCD) ultrasonography is used to indirectly detect CV through recognition of an increase in cerebral blood flow velocity (CBFV). The present study aimed to use TCD ultrasonography to monitor how CBFV changes on both the ipsi- and contralateral sides of the brain in the first 24 hours after patients have received a stellate ganglion block (SGB) to treat CV that persists despite maximum standard therapy.

METHODS

The data were culled from records of patients treated between 2013 and 2017. Patients were included if an SGB was administered following aSAH, whose CBFV was ≥ 120 cm/sec and who had either a focal neurological deficit or reduced consciousness despite having received medical treatment and blood pressure management. The SGB was performed on the side where the highest CBFV had been recorded with 8-10 ml ropivacaine 0.2%. The patient's CBFV was reassessed after 2 and 24 hours.

RESULTS

Thirty-seven patients (male/female ratio 18:19), age 17-70 years (mean age 49.9 ± 11.1), who harbored 13 clipped and 22 coiled aneurysms (1 patient received both a coil and a clip, and 3 patients had 3 untreated aneurysms) had at least one SGB. Patients received up to 4 SGBs, and thus the study comprised a total of 76 SGBs.After the first SGB, CBFV decreased in 80.5% of patients after 2 hours, from a mean of 160.3 ± 28.2 cm/sec to 127.5 ± 34.3 cm/sec (p < 0.001), and it further decreased in 63.4% after 24 hours to 137.2 ± 38.2 cm/sec (p = 0.007). A similar significant effect was found for the subsequent SGB. Adding clonidine showed no significant effect on either the onset or the duration of the SGB. Contralateral middle cerebral artery (MCA) blood flow was not reduced by the SGB.

CONCLUSIONS

To the authors' knowledge, this is the largest study on the effects of administering an SGB to aSAH patients after aneurysm rupture. The data showed a significant reduction in ipsilateral CBFV (MCA 20.5%) after SGB, lasting in about two-thirds of cases for over 24 hours with no major complications resulting from the SGB.

[Molecular mechanism underlying the inhibitory effect of propofol on lipopolysaccharide-induced pyroptosis of mouse bone marrow-derived macrophages]

OBJECTIVE

To investigate the molecular mechanism underlying the inhibitory effect of propofol on pyroptosis of macrophages.

METHODS

Macrophages derived from bone marrow were extracted and divided into three groups: control group, LPS+ATP group and propofol+LPS+ATP group. The control group was not given any treatment; LPS+ATP group was given LPS 1 μg/mL stimulation for 4 h, then ATP 4 mM stimulation for 1 h; Propofol+LPS+ATP group was given propofol+LPS 1 μg/mL stimulation for 4 h, then ATP stimulation for 1 h. After treatment, the supernatant and cells of cell culture were collected. the cell activity was detected by CCK8 and flow cytometry. The inflammatory cytokines IL-1βand IL-18 were detected by Elisa. Western blot was used to detect the expression of caspase-1 protein and TLR4 on cell membran Immunohistochemical fluorescence was used to detect apoptosis of cells.

RESULTS

LPS+ATP significantly decreased the viability of the macrophages and increased the cellular production of IL-1β and IL-18, activation of caspase-1 protein and the expression of TLR-4 on the cell membrane (P &lt; 0.05). Treatment with propofol obviously reversed the changes induced by LPS+ATP.

CONCLUSIONS

LPS+ATP can induce pyroptosis of mouse bone marrow-derived macrophages, and propofol effectively inhibits such cell death, suggesting that propofol anesthesia is beneficial during operation and helps to regulate the immune function of in patients with sepsis.

Effects of ultrasound-guided stellate ganglion block on cervical vascular blood flow: study protocol for a randomized controlled trial

BACKGROUND

The stellate ganglion block (SGB) can lead to vasodilation of the head and neck. However, controversy remains concerning the changes in extracerebral blood flow. The objective of this study is to assess the effects of SGB on the blood flow to the neck.

METHODS

A randomized controlled crossover trial with 38 participants will be conducted. Participants who have primary headaches will be assigned to either group A or B. Patients in group A will receive SGB with 6 ml 1% lidocaine, and after a one-week washout period, they will undergo the second SGB with 6 ml normal saline. In contrast, patients in group B will receive the opposite protocol. Data will be collected at baseline (T0) and at 15 min after the first intervention (T1), 15 min before the second intervention (T2), 15 min after the second intervention (T3) and at a 3-week follow up (T4). T1 is the primary time point for the primary outcome analysis. The primary outcomes include the peak systolic velocity (PSV), the end diastolic velocity (EDV), resistance index (RI) and vessel diameter of the common carotid artery (CCA) and vertebral artery (VA). The secondary outcomes include the rate of ptosis, the rate of conjunctival flushing, and the numerical rating scale (NRS) pain score. Additionally, adverse events (AEs) or serious adverse events (SAEs) will be collected at each assessment point.

DISCUSSION

This study will comprehensively investigate the efficacy of SGB in extracerebral blood flow. Our research may also suggest that SGB will be effective in reducing pain in patients with primary headaches.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, identifier ChiCTR-IOR-17011536 . Registered on 1 June 2017.

Efficacy and safety of stellate ganglion block in chronic ulcerative colitis

AIM

To investigate the efficacy and safety of stellate ganglion block for the treatment of patients with chronic ulcerative colitis.

METHODS

A total of 120 randomly selected patients with chronic ulcerative colitis treated in Cangzhou Central Hospital from January 2014 to January 2016 were included in this study. These patients were divided into two groups: control group (n = 30), patients received oral sulfasalazine treatment; experimental group (n = 90), patients received stellate ganglion block treatment. Clinical symptoms and disease activity in these two groups were compared before and after treatment using endoscopy. Blood was collected from patients on day 0, 10, 20 and 30 after treatment. Enzyme-linked immunosorbent assay was performed to determine interleukin-8 (IL-8) level. The changes in IL-8 level post-treatment in the two groups were compared using repeated measures analysis of variance.

RESULTS

After treatment, clinical symptoms and disease activity were shown to be alleviated by endoscopy in both the control and experimental groups. However, patients in the control group did not have obvious abdominal pain relief. In addition, the degree of pain relief in the experimental group was statistically better than that in the control group (P < 0.05). Ten days after treatment, IL-8 level was found to be significantly lower in the experimental group than in the control group, and the difference was statistically significant (P < 0.05). In addition, adverse events were significantly higher in the control group than in the experimental group, and the difference was statistically significant (χ² = 33.215, P = 0.000).

CONCLUSION

The application of stellate ganglion block effectively improves treatment efficacy in chronic ulcerative colitis, relieves clinical symptoms in patients, and reduces the level of inflammatory factors. Furthermore, this approach also had a positive impact on the disease to a certain extent.