The effect of marked hyperventilation upon tissue levels of NADH, lactate, pyruvate, phosphocreatine, and adenosine phosphates of rat brain

Biochemical issues in estimation of cytosolic free NAD/NADH ratio

Cytosolic free NAD/NADH ratio is fundamentally important in maintaining cellular redox homeostasis but current techniques cannot distinguish between protein-bound and free NAD/NADH. Williamson et al reported a method to estimate this ratio by cytosolic lactate/pyruvate (L/P) based on the principle of chemical equilibrium. Numerous studies used L/P ratio to estimate the cytosolic free NAD/NADH ratio by assuming that the conversion in cells was at near-equilibrium but not verifying how near it was. In addition, it seems accepted that cytosolic free NAD/NADH ratio was a dependent variable responding to the change of L/P ratio. In this study, we show (1) that the change of lactate/glucose (percentage of glucose that converts to lactate by cells) and L/P ratio could measure the status of conversion between pyruvate + NADH and lactate + NAD that tends to or gets away from equilibrium; (2) that cytosolic free NAD/NADH could be accurately estimated by L/P only when the conversion is at or very close to equilibrium otherwise a calculation error by one order of magnitude could be introduced; (3) that cytosolic free NAD/NADH is stable and L/P is highly labile, that the highly labile L/P is crucial to maintain the homeostasis of NAD/NADH; (4) that cytosolic free NAD/NADH is dependent on oxygen levels. Our study resolved the key issues regarding accurate estimation of cytosolic free NAD/NADH ratio and the relationship between NAD/NADH and L/P.

The competitive NMDA antagonist, CGS-19755, improves postischemic hypoperfusion in selectively vulnerable regions in gerbils

We attempted to clarify the effects of an NMDA antagonist on postischemic hypoperfusion in gerbils with 10 min forebrain ischemia and to relate it to postischemic metabolic recovery. We administered 10 mg/kg of CGS-19755, a competitive NMDA antagonist, or the same volume of saline intraperitoneally 30 min before the vascular occlusion. In 26 gerbils, we measured local cerebral blood flow (LCBF) 60 min after the reperfusion using [14C]iodoantipyrine autoradiography. In 20 gerbils, the effects on metabolic recovery were determined by serial measurements of intracellular pH, adenosine triphosphate (ATP) and the ratio between phosphocreatine and inorganic phosphate (PCr/Pi) until 60 min after reperfusion using 31P-magnetic resonance spectroscopy. In another group of 24 gerbils, we determined histopathological damage 24 h after the ischemia. The LCBF autoradiograms in the control group consistently demonstrated a typical postischemic hypoperfusion, i.e. homogeneous 50-75% reduction of blood flow in all forebrain structures. In contrast, CGS-19755 pretreatment animals showed highly heterogeneous LCBF declines, and significantly higher LCBF values were observed in the frontoparietal cortex and thalamus both of which were the most vulnerable area in this model. No significant LCBF change was observed in sham operated animals with or without CGS-19755 pretreatment. The postischemic recovery of PCr/Pi in gerbils pretreated with CGS-19755 was significantly better than that in the control animals. No significant differences in the recovery of ATP and intracellular pH were observed. The histological damage in the CGS-19755-treated group was less extensive than those in the saline-treated group. CGS-19755 pretreatment improved postischemic hypoperfusion and PCr/Pi recovery in the 10-min forebrain ischemia model in gerbils. The improvement of postischemic hypoperfusion in selectively vulnerable regions suggests that the activation of NMDA receptors may be related to the mechanism of developing postischemic hypoperfusion.

Quantitative EEG during progressive hypocarbia and hypoxia. Hyperventilation-induced EEG changes reconsidered

To investigate the role of cerebral hypoxia as a causative factor in the alteration of the qEEG during hyperventilation, qEEG changes caused by progressive hypocapnia were compared with qEEG changes due to progressive normobaric hypoxia in two parallel groups of 12 and 10 healthy male subjects (age 20-27 years), respectively. In the first group, qEEG records were obtained before and during hyperventilation to pCO2 levels of 4.0, 3.0 and 2.0 kPa. In the second group, the qEEG samples were taken before and during hypoxia with hemoglobin oxygen saturations of 80, 70 and 60%. In both groups, blood flow velocity in the middle cerebral artery was also recorded. Hyperventilation caused an exponential increase in slow activity and a decrease in alpha power. No shift in the alpha mean frequency and alpha peak frequency was observed, except with the pCO2 level of 4.0 kPa, which caused an increase in both variables. Hypoxia with a hemoglobin oxygen saturation of 60% caused a much less pronounced increase in slow activity. No change in total power in the alpha band was found, but both the alpha peak frequency and alpha mean frequency decreased. Lesser degrees of hypoxia caused only minimal EEG changes. Blood flow velocity was decreased by hyperventilation but increased by hypoxia. It is concluded that the EEG changes observed during hyperventilation must mainly or totally be attributed to factors other than cerebral hypoxia.

Cerebral intracellular pH regulation during hypercapnia in unanesthetized rats: a 31P nuclear magnetic resonance spectroscopy study

The energy metabolism and the brain intracellular pH regulation under arterial CO2 tensions of 25-90 mm Hg were investigated in unanesthetized spontaneously breathing rats by in vivo phosphorus nuclear magnetic resonance spectroscopy (31P NMR). The 31P brain spectra, recorded with a high resolution spectrometer (AM 400 Brucker), allowed repeated non-invasive measurements of cerebral pH (pHi), phosphocreatine (PCr), inorganic phosphate (Pi) and adenosine triphosphate (ATP) levels in 15 rats breathing a gas mixture containing 21% O2, N2, and a varied percentage of CO2. The pHi decreased significantly when the paCO2 was increased by hypercapnia. The percentage of pH regulation, estimated from the linear regression analysis of pHi versus the logarithm of the paCO2 was 78%. This result indicates that spontaneously breathing unanesthetized animals have better pHi regulation under hypercapnia investigated than that estimated for higher levels of hypercapnia in previous studies on unanesthetized animals, suggesting that there is a threshold for this highly efficient regulation. Furthermore, there were no significant correlations between the PCr, ATP and Pi levels and the paCO2 levels during hypercapnia. This indicates that physiological variations of the CO2 tension in the blood, and consequently in the brain parenchyma, have little effect on cerebral energy metabolism in unanesthetized spontaneously breathing animals.

1H and 31P NMR measurement of cerebral lactate, high-energy phosphate levels, and pH in humans during voluntary hyperventilation: associated EEG, capnographic, and Doppler findings

In order to explore the sensitivity of spatially resolved 1H and 31P NMR spectroscopy on a whole-body NMR instrument, cerebral metabolic changes in human volunteers were measured during hyperventilation provocation. During hyperventilation the flow velocity in the middle cerebral artery decreased significantly and the EEG showed a marked increase in slow activity. 1H NMR spectra revealed an increase in cerebral lactate concentration. 31P NMR spectra showed no changes in ATP or PCr peak heights, but a shift toward tissue alkalosis was derived from changes in Pi chemical shift. During subsequent recovery, lactate concentration decreased and a slight intracellular acidosis was detected. In three experiments broadening of the lactate resonance peak resulted in separation into two components at 1.32 and 1.48 ppm, in which the latter signal possibly arose from alanine.

Response of the cerebral circulation to profound hypocarbia in neonatal lambs

Hyperventilation to extremely low arterial carbon dioxide tension (PaCO2) has been used in the management of persistent pulmonary hypertension in newborn infants. With progressive hypocarbia, cerebral vasoconstriction occurs, raising the concern that extreme hypocarbia may result in cerebral oxygen deprivation. Therefore, I evaluated regulation of the cerebral circulation during acute hypocarbia in 10 newborn lambs. Whole-brain and regional blood flows measured using radioactive microspheres, arterial and venous (sagittal sinus) blood gases, and oxygen contents were measured in each lamb at four arterial carbon dioxide tensions. Whole-brain oxygen delivery, oxygen consumption, and fractional oxygen extraction were calculated. Finally, arterial and venous lactate concentrations were measured to assess cerebral lactate production. Whole-brain blood flow (CBF) decreased in a nonlinear fashion as PaCO2 ranged from 46 to 12 mm Hg [In(CBF) = 0.025(PaCO2) + 3.38; r = 0.70, p less than 0.001]. Similar responses were demonstrated for all regional blood flows examined. Cerebral fractional oxygen extraction (E) increased in a nonlinear fashion [In(1-E) = 0.023(PaCO2)-1.37; r = 0.80, p less than 0.001], and cerebral metabolic rate for oxygen was unchanged with hypocarbia. Cerebral venous lactate concentration increased significantly (3.49 +/- 0.23 vs. 2.01 +/- 0.22 mM, p less than 0.001) during severe hypocarbia (PaCO2 of less than 22 mm Hg), and the arterial-venous lactate concentration difference became negative. These results demonstrate uniform responses of whole-brain and regional blood flows and stable cerebral oxygen consumption during moderate and severe hypocarbia. Although there is evidence for cerebral lactate production during severe hypocarbia, this is not likely to indicate cerebral hypoxia as oxygen consumption does not change.

Cerebral effects of extended hyperventilation in unanesthetized goats

Thirty-six adult, male unanesthetized goats were hyperventilated to a PaCO2 level of 16-18 mm Hg for 6 hours. Arterial and sagittal sinus blood and cerebrospinal fluid were analyzed for pH, blood gases, bicarbonate, lactate, and pyruvate before hyperventilation, during hyperventilation, and after the termination of hyperventilation. Total cerebral blood flow, regional brain blood flows, and cerebral metabolic rate for oxygen were calculated from the distribution of radioactive microspheres. Intracranial pressure was measured in either the right or left cerebral ventricle. With the initiation of hyperventilation, cerebral blood flow and cerebral metabolic rate for oxygen fell significantly (64 +/- 5 ml/100 g/min to 41 +/- 3; 4.6 +/- 0.3 ml O2/100 g/min to 3.6 +/- 0.2), but both returned to prehyperventilation values within 6 hours of hyperventilation. With termination of hyperventilation, cerebral blood flow and cerebral metabolic rate for oxygen increased significantly above control levels (64 +/- 5 vs. 105 +/- 9; 4.6 +/- 0.3 vs. 5.4 +/- 0.4). Intracranial pressure was unaffected by hyperventilation or its termination. Arterial and sagittal sinus blood and cerebrospinal fluid pH increased with hyperventilation but returned to control values by 6 hours. However, pH was still significantly elevated at 6 hours. Lactate and pyruvate followed a similar pattern except in the cerebrospinal fluid, where both increased throughout the course of hyperventilation. There were no significant differences in the lactate:pyruvate ratio. On termination of hyperventilation, pH of the arterial and sagittal sinus blood and cerebrospinal fluid fell below control levels. Bicarbonate values decreased in all fluid compartments and were still below control values 2 hours after the cessation of hyperventilation.(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebral physiological and metabolic effects of hyperventilation in the neonatal dog

To clarify the changes that occur during marked hypocarbia in the neonate, we measured brain blood flow and metabolite levels after 90 minutes of hyperventilation in neonatal dogs. Brain blood flow decreased significantly in diencephalon, brainstem, and spinal cord but not in cerebral cortex or white matter. There was no substantial change in the electroencephalogram. Lactate concentrations, both in telencephalon and in superior sagittal sinus blood, increased significantly, although there was no alteration in levels of ATP or phosphocreatine. Marked hypocarbia in the neonatal dog produces an elevated brain lactate level that may be related to changes in glycolytic rate rather than to tissue ischemia or hypoxia.

ATP content in isolated mammalian nerve cells assayed by a modified luciferin-luciferase method

ATP content in a nerve cell isolated from dorsal root ganglia of adult guinea-pigs by collagenase was measured by a newly developed technique modified from the conventional luciferin-luciferase methods. A small volume (4 microliters) of the nerve cell suspension, which contained 10-300 nerve cells (3-100 X 10(-4) microliters of cellular volume) under view of an inverted, phase-contrast microscope, was heat-treated for about 1 s by flame of an alcohol lamp. This heat-treated cell suspension was then reacted with a luciferin-luciferase solution. Light flux from the bioluminescence thus elicited gave an ATP content in single nerve cell, 27 pg (mean) +/- 10 pg (S.D.). ATP concentration in a nerve cell was calculated as 1.7 mM (mean) +/- 0.6 mM. The ATP content in a nerve cell was reduced when the nerve cells were exposed to KCN (5 microM) or dinitrophenol (20 microM), respectively.

Effects of hyperventilation on cerebral blood flow and brain tissue metabolism in normotensive and spontaneously hypertensive rats

Cerebral vascular carbon dioxide (CO2) reactivities were compared in normotensive (NTR) and hypertensive (SHR) rats. Cerebral blood flow (CBF) in cortex and thalamus were evaluated before and during one hour of hyperventilation. After one hour of hyperventilation brain lactate, pyruvate, and ATP concentrations were also determined. Significant and similar reductions of CBF due to hyperventilation induce hypocapnia were found in both NTR and SHR groups. In contrast the percent increase in cerebrovascular resistance (CVR) per unit decrease in paCO2 was significant, indicating that hypocapnia induced vasoconstriction is greater in NTR than in SHR groups. During hyperventilation the average value for lactate in the NTR group was 3.98 mM/kg. In contrast it was 3.15 mM/kg in the SHR group, a significant difference (p less than 0.05). When paCO2 fell below 15 mm Hg the cerebral lactate increased strikingly in the NTR group and cortical CVR was reduced suggesting that an accumulation of the ischemic metabolites caused dilatation of the constricted cerebral vessels. In contrast the SHR group disclosed no such changes. The increase CVR characteristic of SHR appeared to diminish the cerebral vasoconstrictive response to hypocapnia. As a result ischemic metabolites in the brain do not increase in this group to the degree that they do in NTR.

The young-adult and normally aged brain. Its blood flow and oxidative metabolism. A review--part I

Blood flow and oxidative metabolism of the mature and healthy young-adult human brain account for about 20% of the cardiac output and about 20 and 25% of the requirements of oxygen and glucose, respectively, for the whole body. Normal cerebral aging is associated with only smaller reductions in the cerebral metabolic rates of oxygen and glucose while cerebral blood flow would seem to be unchanged. The age-dependent reduction in oxidative brain metabolism may be related to a decline in glycolytic flux due to a diminution of enzyme activities also involving acetylcholine synthesis. This metabolic reduction with age may be tentatively accounted for by a physiologically occurring loss of neurons, dendrites and dendritic spines in distinct brain areas. The mechanisms of autoregulation of cerebral blood flow, of CO2 reactivity of the brain vessels, of arterial hypoxemia on cerebral blood flow and their effects on oxidative and energy metabolism are well documented in young-adult brain. There is, however, no or only minimal information on the responsiveness of the normally aged brain to changes of these important biological parameters controlling and influencing brain blood flow and metabolism.

Effects of severe arterial hypocapnia on regional blood flow regulation, tissue PO2 and metabolism in the brain cortex of cats

The effect of a stepwise decrease in PaCO2 from 3.9-1.6 kPa on rCBF, rCMRO2, tissue PO2 and concentrations of glucose, lactate, pyruvate, ATP, ADP, AMP and phosphocreatine in the brain cortex was studied in cats lightly anaesthetized with sodium pentobarbital. 1. Moderate lowering of PaCO2 to 2.5 kPa induced in all animals a homogeneous decrease of rCBF in corresponding areas of the right and left hemisphere. Mean rCBF fell from 129.2 to 103.1 ml X 100 g-1 X min-1, while rCMRO2 remained unchanged (12.7-12.9 ml X 100 g-1 X min-1). The tissue PO2 frequency histograms showed a shift to lower values without indicating the presence of brain tissue hypoxia. 2. Severe arterial hypocapnia (PaCO2 = 1.6 kPa) caused an inhomogeneous blood flow reaction. Both further decreased as well as increased rCBF values were measured simultaneously in the brain cortex of individual animals (mean rCBF = 97.6 ml X 100 g-1 X min-1). At the same time tissue PO2 measurements and metabolite assays indicated the presence of pronounced brain tissue hypoxia. The tissue concentrations of lactate and pyruvate and the lactate/pyruvate ratio were significantly increased, while the phosphocreatine concentration was significantly reduced. In addition, rCMRO2 decreased to 11.3 ml X 100 g-1 X min-1. The results provide conclusive evidence that severe arterial hypocapnia leads to an insufficient O2 supply of the brain cortex, which in turn seems to counteract the influence of hypocapnia on cortical blood flow regulation.

Cerebral energy metabolism in diving and non-diving birds during hypoxia and apnoeic asphyxia

1. Cerebral energy metabolism during apnoeic asphyxia and steady-state hypoxia was compared in ducks and chickens; ducks tolerate apnoeic asphyxia 3-8 times longer than chickens. 2. Fluctuations in the reduced form of respiratory chain nicotinamide adenine dinucleotide (NADH) were monitored from the left cerebral hemisphere by a noninvasive fluorometric technique and used as an indicator of mitochondrial hypoxia. NADH fluorescence was expressed in aribtrary units (a.u.) where 100 a.u. was defined as the fluorescence change from normoxia to anoxia. Electroencephalogram (e.e.g.) and surface Po2 were recorded from the right hemisphere. 3. After 1 min of asphyxia NADH fluorescence increased by 37 a.u.+/-3.60 S.E. of mean (n=54) in paralysed chickens and 8 a.u.+/-1.41 (n=55) in aralysed ducks. After 2 min the fluorescence increased by only 15 a.u.+/-1.95 in ducks. 4. Both species showed an isoelectric e.e.g. when fluorescence increased by approximately 35 a.u., indicating that anaerobic ATP production in ducks did not maintain brain function (e.e.g.) for a greater accumulation of respiratory chain NADH. 5. At a given decrease in tissue Po2 ducks and chickens showed the same level of NADH increase, indicating that both species are equally dependent on tissue Po2 for the maintenance of redox state. 6. We conclude that biochemical adjustment which enhance anaerobic ATP production and/or prolong oxidative phosphorylation during progressive hypoxia are not responsible for increased cerebral tolerance to apnoeic asphyxia in the duck.

Cerebral cortical microfluorometry at isosbestic wavelengths for correction of vascular artifact

Microfluorometric measurements of cerebral cortical mitochondrial respiration in vivo are obscured by hemodynamic and oximetric artifacts. Isosbestic fluorometry provides appropriate correction for these vascular phenomena and permits simultaneous evaluation of mitochondrial nicotinamide adenine dinucleotide redox state, microcirculatory volume, and hemoglobin oxygenation.

Lactate dehydrogenase (LD), hydroxybutyrate dehydrogenase (HBD), and LD-isoenzymes in brain tissue

The total activities of lactate dehydrogenase (LD) and hydroxybutyrate dehydrogenase (HBD), and the LD isoenzyme distribution were determined in tissue samples taken in vivo from different parts of the rabbit brain, and in cortical grey, subcortical white, and cerebellar tissue from man. The total LD and HBD activities were found to be higher in the brain stem than in the cerebral hemisphere, basal ganglia, and cerebellum of the rabbit brain. The isoenzyme distribution in the brain stem and the cerebellum showed an anodal shift, i.e., significantly higher activities of LD1 compared with the cerebral hemisphere and the basal ganglia. In man the total LD activity was found to be lower in white than in grey matter, although the isoenzyme patterns did not differ. The implications of these findings in relation to the LD isoenzyme pattern in serum after traumatic brain injury are discussed.

Cyanide intoxication in Macaca mulatta. Physiological and neuropathological aspects

Sodium cyanide was infused intravenously in 11 lightly anaesthetised and spontaneously breathing M. mulatta. In most, the EEG, ECG, respiratory rate, blood pressure, cerebral venous sinus pressure, end-tidal pCO2 and body temperature were recorded. Blood gases, pH, lactate and pyruvate were estimated in arterial and venous sinus blood samples. There was an initial hyperventilation with tetany in all animals. A rapid rate of cyanide infusion led to apnoea. An isoelectric or near-isoelectric EEG was usually precipitated by bradycardia often with additional hypotension. Neither epileptic seizures nor their EEG concomitants were seen at any stage. Three animals died of early heart failure. Brain damage was seen in 4 animals surviving up to 98 hr. White matter was involved in all. Ischaemic neuronal alterations, restricted to the striatum of one animal, were attributed to major circulatory complications. It was concluded that under these experimental conditions there is no evidence for hypoxic neuronal damage of purely histotoxic type.

Cyanide intoxication in the rat: physiological and neuropathological aspects

Sodium cyanide was given to rats by intravenous infusion at a rate that would avert apnoea (the first sign of overdosage) in the majority. There was full physiological monitoring in a group under anaesthesia and more limited monitoring in an unanaesthetized group. White matter was damaged in six animals and grey matter additionally in only one. It was concluded that cyanide can damage neurones only through the medium of secondary effects on circulation and respiration.

Cerebrospinal fluid and arterial lactate, pyruvate and acid-base balance in patients with intracranial hemorrhages

Lactate and pyruvate concentrations and acid-base balance in cerebrospinal fluid (CSF) and arterial blood were determined in patients with intracranial hemorrhages (28 subarachnoid hemorrhages and 15 intracerebral hemorrhages). A greater increase in CSF lactate and lactate-pyruvate ratio (L/P ratio) was observed in patients with impairment of consciousness, focal neurological deficits, poor prognosis, or CSF pressures higher than 300 mm H2O. A combination of CSF lactate greater than 2.5 mM per liter, L/P ration above 20, bicarbonate less than 20.4 mEq per liter, pH below 7.276, or arterial PCO2 below 31.5 mm Hg seems to indicate poor prognosis from intracranial hemorrhage. The mechanism of hyperventilation in acute cerebrovascular diseases and of CSF pH regulation in acid-base disturbances was also discussed.

Reduced nicotinamide adenine dinucleotide fluorescence and cortical blood flow in ischemic and nonischemic squirrel monkey cortex. 2. effects of alterations in arterial carbon dioxide tension, blood pressure, and blood volume

The fluorescence of reduced nicotinamide adenine dinucleotide (NADH) from cerebral cortex was measured before, during, and after middle cerebral artery (MCA) occlusion and then at death of the animal. In normal cortex, NADH remained constant throughout a wide range of variations in blood pressure and Paco2. In ischemic cortex, NADH levels were higher in hypovolemic hypotensive animals than in normotensive normovolemic animals. Neither hypercapnia nor hypocapnia was effective in decreasing NADH in regions of ischemia, but the latter was associated with a degree of hypotension that interfered with interpretation of data. NADH returned to normal with restoration of flow, supporting the reversibility of this degree of ischemia. The high levels of NADH at death, compared to those during ischemia, are consistent with incomplete ischemia in this model of cerebral infarction.

Reduced nicotinamide adenine dinucleotide fluorescence and cortical blood flow in ischemic and nonischemic squirrel monkey cortex. 1. animal preparation, instrumentation, and validity of model

Reduce nicotinamide adenine dinucleotide (NADH) fluorescence was recorded from an avascular area on the squirrel monkey cortex prior to, during, and after focal incomplete ischemia. By using the instrumentation described, stable recordings were obtained free from hemoglobin artifact and with only minimal photodecomposition. Pentobarital was compared to urethane and halothane as the anesthetic agent and was found acceptable for these types of studies in the dosages used. NADH levels were constant prior to ischemia, increased during ischemia, returned to pre-ischemic levels after restoration of blood flow, and then increased greatly at death produced by anoxia. The use of the infrared microscope for semiquantitative measurements of cortical blood flow throughout the duration of these acute studies was investigated and found to the reliable.

Energy state and glycolysis in human cerebral edema

✓ A new freeze-stop device using a liquid nitrogen reservoir and an automatic biopsy mechanism has been developed, suitable for rapid, sterile, and standardized sampling of cerebral tissue in man. In animal experiments a 200 mg piece of cerebral cortex was cooled from a room temperature of 18°C to −40°C within 7 sec which is twice as fast as when it was immersed in liquid N2. The method was then applied to metabolic tissue studies of perifocal edematous cortex from patients undergoing neurosurgery for intracranial tumors. Energy-rich phosphate compounds or parameters of the energy state were found to be less affected in this type of brain edema than the glycolytic activity which was markedly enhanced, indicated by lactic and pyruvic acid determinations. The tissue water content correlated closely with the lactic acid concentration, and very little with measurements of the energy state such as the energy charge potential or the adenosinetriphosphate-adenosinediphosphate (ATP/ADP) ratio. It is suggested that in perifocal brain edema increased levels of lactic acid are associated with mechanisms leading to an increased water uptake.

Hyperventilation and cerebral blood flow

Hypocapnic-hyperventilation has a profound, but probably temporary, effect on CBF, producing approximately a 2% decline in CBF for each 1 torr decline in P co co2 . This effect appears to be mediated through changes in perivascular pH of the cerebral resistance vessels acting directly on the vessel wall. At low P co co2 the vasoconstrictor effect of short-term hypocapnic-hyperventilation is attenuated by resultant cerebral hypoxia. During prolonged hyperventilation CBF returns toward normal as the pH in the CSF is restored.

Short-term hypocapnic-hyperventilation can be lifesaving in the treatment of acute intracranial hypertension. On the other hand, prolonged hyperventilation has not been convincingly shown to benefit patients, whether with severe head injury or cerebral infarction, or during carotid endarterectomy without bypass.