Cerebral circulatory and metabolic effects of hypotension produced by deep halothane anaesthesia

Pretreatment with a competitive NMDA antagonist D-CPPene attenuates focal cerebral infarction and brain swelling in awake rats

The purpose of the study was to assess effects of the competitive N-methyl-D-aspartate (NMDA) receptor antagonist D-(E)-4-(3-phosphonoprop-2-enyl)piperazine-2-carboxylic acid (D-CPPene) upon focal cerebral infarction and brain oedema in the rat. Focal cerebral ischaemia was produced by permanent occlusion of the middle cerebral artery under halothane anaesthesia. The anaesthetic gas was discontinued immediately after the occlusion and the rats were killed 24 hours later. Cerebral infarction and brain swelling were each assessed on the frozen brain sections at 8 predetermined coronal planes. Pretreatment with D-CPPene (4.5 mg/kg i.v. followed by continuous infusion at 3 mg/kg/h until sacrifice) 15 minutes prior to MCA occlusion, significantly reduced the volume of infarction in the cerebral hemisphere by 29% (p < 0.05). Brain swelling, obtained by subtracting the nonischaemic hemispheric volume from the ischaemic hemispheric volume, was significantly reduced with D-CPPene treatment and the mean reduction in swelling (34% less than the controls: p < 0.001) proportionately similar to the decrease in infarct volume in the same animals. These data indicate that systemic administration of the competitive NMDA receptor antagonist D-CPPene has neuroprotective effects against ischaemic brain damage, and the reduction in brain swelling occurs in parallel with the reduction in ischaemic damage.

Shy-Drager syndrome. Effect of fludrocortisone and L-threo-3,4-dihydroxyphenylserine on the blood pressure and regional cerebral blood flow

In nine cases of Shy-Drager syndrome, the changes in blood pressure and cerebral blood flow on sitting up from a supine position were studied. The influence of fludrocortisone, a synthetic mineralocorticoid, and L-threo-3,4-dihydroxyphenylserine (DOPS), a precursor of norepinephrine, on these changes was examined. On sitting up, the regional cerebral blood flow (rCBF) measured by Xe133 inhalation showed a tendency to decrease. Fludrocortisone reduced the fall of the mean blood pressure significantly. DOPS reduced the fall of both the diastolic blood pressure and rCBF significantly.

Autoregulation of cerebral blood flow in experimental focal brain ischemia

The relationship between systemic arterial pressure (SAP) and neocortical microcirculatory blood-flow (CBF) in areas of focal cerebral ischemia was studied in 15 spontaneously hypertensive rats (SHRs) anesthetized with halothane (0.5%). Ischemia was induced by ipsilateral middle cerebral artery/common carotid artery occlusion and CBF was monitored continuously in the ischemic territory using laser-Doppler flowmetry during manipulation of SAP with I-norepinephrine (hypertension) or nitroprusside (hypotension). In eight SHRs not subjected to focal ischemia, we demonstrated that 0.5% halothane and the surgical manipulations did not impair autoregulation. Autoregulation was partly preserved in ischemic brain tissue with a CBF of greater than 30% of preocclusion values. In areas where ischemic CBF was less than 30% of preocclusion values, autoregulation was completely lost. Changes in SAP had a greater influence on CBF in tissue areas where CBF ranged from 15 to 30% of baseline (9% change in CBF with each 10% change in SAP) than in areas where CBF was less than 15% of baseline (6% change in CBF with each 10% change in SAP). These findings demonstrate that the relationship between CBF and SAP in areas of focal ischemia is highly dependent on the severity of ischemia. Autoregulation is lost in a gradual manner until CBF falls below 30% of normal. In areas without autoregulation, the slope of the CBF/SAP relationship is inversely related to the degree of ischemia.

Continuous nimodipine treatment attenuates cortical infarction in rats subjected to 24 hours of focal cerebral ischemia

Focal cerebral infarction and edema were measured in rats (Wistar, Fisher 344, and spontaneously hypertensive strains) pretreated with nimodipine (2 micrograms/kg/min i.v.) or its vehicle and subjected to the tandem occlusion of the middle cerebral and common carotid arteries. Animals awoke from anesthesia 10-15 min after onset of ischemia and continued to receive treatment over a 24-h survival period. Cortical infarction and edema were quantified by image analysis of frozen brain sections processed for histology. Nimodipine-treated rats developed 20-60% smaller cortical infarct volumes than controls (p less than 0.002). Cortical edema was reduced proportionately to the decrease in infarct volume and constituted approximately 36% of the infarct volume. Nimodipine caused a mild hypotensive response that did not aggravate ischemic brain damage. The results indicate that continuous nimodipine treatment, started before induction of focal cerebral ischemia, can attenuate ischemic brain damage and edema as late as 24 h after the onset of ischemia.

Cerebrovascular permeability following MCA occlusion in the rat. The effect of halothane-induced hypotension

A quantitative autoradiographic technique that utilizes carbon-14-aminoisobutyric acid (14C-AIB) as a tracer was used to study alterations in cerebral microvascular permeability in 15 rats. Five were "sham-operated" controls and 10 underwent microsurgical, unilateral occlusion of the proximal middle cerebral artery (MCA). Histological changes indicative of focal cerebral ischemia were observed in only the latter 10 animals. These changes were confined to tissue normally perfused by the occluded MCA. After MCA occlusion, five animals were also subjected to transient halothane-induced hypotension (mean arterial blood pressure 50 mm Hg) for 20 to 30 minutes. Only in these five animals were blood-to-brain transfer constants (ki) significantly increased (by approximately 100%) at 4 hours after MCA occlusion. The topographical distribution of this alteration in cerebral microvascular permeability corresponded closely with the histological changes. Neither proximal MCA occlusion nor halothane-induced hypotension alone was associated with any focal or diffuse increase in ki after 4 hours.

Effects of profound hypotension on cerebral blood flow during surgery for intracranial aneurysms

The progression of changes in cerebral blood flow (CBF) and neurological status were measured in 12 patients in whom profound hypotension (mean arterial blood pressure (MABP): 30 to 40 mm Hg) was used during intracranial aneurysm surgery. Nine patients (Group I) showed autoregulation of CBF to an MABP of 40 to 50 mm Hg during surgery. None of these patients had arterial spasm preoperatively. Postoperatively, mild flow disturbances were noted at the site of retraction. Three Group I patients developed arterial spasm postoperatively, but there was no associated neurological deterioration. The remaining three patients (Group II) had impaired autoregulation during surgery, and CBF decreased by 35% to 65% at an MABP of 50 mm Hg. Two of these patients had angiography immediately before surgery, and both showed moderate to severe arterial spasm. Relatively severe flow disturbances were noted postoperatively at the site of retraction, and two patients developed ischemic deficits of late onset. Brain retractor pressure and the degree and duration of hypotension were equivalent in the two patient groups. There was no correlation between intraoperative reductions in CBF (to as low as 20 ml/100 gm/min in the unretracted hemisphere) and immediate postoperative neurological deficits. The use of halothane and mannitol and the relatively short duration of the flow reductions were suggested as factors contributing to the protection from ischemia that was observed. Arterial spasm was found to produce hemodynamic instability and reduced CBF, although neurological status was unaffected in the majority of patients. Patients with impaired autoregulation during surgery were at increased risk of delayed ischemic complications postoperatively, and showed characteristic flow disturbances at all three stages of their clinical course.

Postoperative intracranial pressure in patients operated on for cerebral aneurysms following subarachnoid hemorrhage

The postoperative intracranial pressure (ICP) in 36 patients operated on for cerebral aneurysm following subarachnoid hemorrhage was studied. Not only was the baseline ICP significantly lower in patients whose outcome was assessed as "good" as compared with those patients with a worse outcome at 1 month after surgery, but also the height of the plateau waves and B-waves was significantly less in the patients who did well. The baseline ICP and the height of the B-wave formation were unrelated to the position of the aneurysm. Plateau waves were marginally significantly higher in aneurysms of the anterior communicating artery complex. Neither preoperative hypertension nor the use of antifibrinolytic agents made any difference to postoperative ICP. In patients with cerebral arterial vasospasm found preoperatively on the angiograms, the ICP tended to be lower in the postoperative period than in those without spasm.

Vasodilator drugs: systemic and regional considerations

Therapeutic use of vasodilator drugs depends on the differential actions of these drugs on regional vascular beds. These differences include selective action on small and large arteries, differential potency on arterial and venous smooth muscle, and selectivity for autonomic receptors. The directly acting sodium nitroprusside and glyceryl trinitrate exemplify many of these differences as well as shared effects in the systemic, coronary and cerebral circulations.

Local cerebral blood flow and the electrocorticogram during sodium nitroprusside hypotension

Changes in local cerebral blood flow during sodium nitroprusside hypotension were measured using the hydrogen electrode technique. At mean arterial pressures from 90% to 50% of control values, local cerebral blood flow showed a significant decrease by 20%. When blood pressure was reduced below 50%, the local cerebral blood flow increased significantly and approached control levels. It is suggested that the flow increase may be due to local hypoxia. Associated with this increase were electrocorticogram changes indicative of hypoxia. The significant decrease in mean local cerebral blood flow and the large range of flows seen during mild hypotension indicate that autoregulation is impaired. During hypotension, intracranial pressure increased by, at most, 3 mm Hg. Cardiac output was usually unaffected and was never decreased by more than 20%.

The histopathology of experimental spinal cord trauma. The effect of systemic blood pressure

The early sequential histopathological alterations following a concussive paraplegic injury to the posterior thoracic spinal cord in cats were studied. The lack of significant progression of hemorrhages over a 4-hour period after injury indicates that most hemorrhages probably occur within the first hour. The marked enhancement or retardation of hemorrhages in the post-injury period, when the blood pressure was increased or decreased, respectively, demonstrates the loss of autoregulation of spinal cord vasculature at the trauma site after a concussive paraplegic injury. Progressive edema formation was evident over a 4-hour period following injury, and it could be enhanced or retarded by elevation or reduction of the systemic blood pressure.

Control of cerebral vascular smooth muscle during general anaesthesia

The effects of some general anaesthetics, for example thiopentone, Althesin (alphaxalone + alphadolone) and ketamine, on cerebral vascular smooth muscle are those which would be expected from their metabolic actions. With other anaesthetics, mainly those administered by inhalation, and especially the volatile agents, cerebral blood flow increases in excess of the metabolic activity, which is usually depressed to varying degrees. During general anaesthesia with any of these agents, responses to changes in arterial Pco2 or blood pressure are maintained. Furthermore, when seizure activity occurs during enflurane administration, there is a flow response to the associated metabolic stimulation. The time course of the flow response to the metabolically depressant drug Althesin has been measured in baboons and shown to be very rapid. Wtih this drug cerebrovascular resistance begins to increase within 2 s of its arrival in the brain. This rapid flow change occurs also after sympathetic denervation. Extracellular fluid pH of the cortex does not alter until after the initiation of the vascular smooth muscle response.

Cerebral arterial blood flow and aneurysm surgery. Part 2: Induced hypotension and autoregulatory capacity

A study of 21 patients was conducted to clarify the autoregulatory capacity in patients subjected to induced hypotension during intracranial surgery for saccular aneurysms. Trimethaphan camsylate (Arfonad) was used for induced hypotension and arterial blood flow was measured with an electromagnetic flow probe on the internal carotid artery or one of its main intracranial branches. In Grade I and II patients the control arterial blood pressure (ABP) ranged from a mean of 90 to 135 mm Hg (average 110 mm Hg), with a lower level of autoregulation (LLAR) from 35 to 85 mm Hg (average 62 mm Hg). Grade III patients had a control ABP of between 105 and 145 mm Hg (average 124 mm Hg) and the LLAR was found to be between 60 and 95 mm Hg (average 76 mm Hg). There was a significant difference between the two groups with regard to both the control ABP and the LLAR. A surprising result obtained from these data was that the average lower autoregulatory range (the difference between control ABP and LLAR) is practically the same in the two groups. A systematic investigation of the upper limit of autoregulation was not possible for ethical reasons. In those few patients in whom spontaneous increase in the ABP made such observations possible, upper limits up to 150 mm Hg with a total autoregulatory capacity of about 75 mm Hg were observed. In some patients, however, lower limits and cing that the upper limit of autoregulation is markedly influenced by several factors.

Autoregulation of cerebral blood flow during controlled hypotension in baboons

The effect of graded, progressive hypotension on the autoregulation of cerebral blood flow was studied in anaesthetised baboons. Progressive hypotension was produced over a period of four to five hours, either by graded haemorrhage or by the administration of increasing concentrations of hypotensive drugs. During haemorrhagic hypotension autoregulation was maintained until the mean arterial pressure had decreased to 65% of its baseline value, below which cerebral blood flow was pressure passive. In those animals subjected to drug-induced hypotension, autoregulation persisted to lower levels of mean arterial pressure (35-40% of baseline). It is postulated that under conditions of haemorrhagic hypotension, constriction of the extraparenchymal cerebral vessels in response to sympathetic stimulation decreases the possible range of autoregulation in the anaesthetised baboon.

[EEG effects of sodium nitroprusside and hemodynamic references]

A study was performed on baboons (Papio papio) of various hemodynamic and EEG effects of sodium nitroprussiate (SNP), substance with powerful vasodilator action. Three different procedures of drug injection were used: (1) in isolation, either in doses close to those used in clinical practice or in high doses; (2) after neuroleptanalgesia (NLA); (3) after causing vasospasm. With isolated SNP, effects on blood pressure were unstable; in certain cases hypotension could be maintained only with toxic doses. Hypotension was facilitated when NLA had been previously induced. At low doses the cerebral blood flow (CBF) was practically unmodified, whereas at toxic doses it first increased then decreased. In animals under NLA, the CBF drop was only moderate, suggesting persistence of adequate spasm, CBF was significantly improved through SNP. The EEG did not undergo sizeable change at low SNP doses given in isolation; toxic doses always induced alterations with peculiar morphology, but developing only tardily after SNP perfusion was begun. This lag may indicate that hypotensive and toxic SNP effects are dissociated. These alterations suggest that screening of the EEG is necessary during prolonged administration of SNP, e.g., in surgical procedures. Combining NLA and SNP (at low doses) causes EEG deceleration, but no great alteration of the rhythms, as observed during other types of controlled experimental hypotension. Hence, cerebral circulation may be relatively well protected during SNP hypotension.

The effect of halothane anaesthesia upon cerebral oxygen consumption in the rat

The influence of halothane (0.6 and 2%) upon cerebral (cortical) blood flow (CBF) and cerebral metabolic rate for oxygen (CMRo2) was studied in artificially ventilated rats, using a modified technique of Kety & Schmidt (1948). The values obtained in halothane anaesthesia were compared to those recorded in nitrous oxide anaesthesia, or to those measured in unanesthetized animals given an analgesic drug (fentanyl citrate). Although it could be confirmed that halothane induces vasodilatation in the brain, there were relatively small differences in CBF between the groups. The results demonstrate that, in the rat, halothane depresses CMRo2 in a dose-dependent way. With 0.6% halothane, CMRo2 was reduced by 20-30% and, with 2% halothane, CMRo2 was reduced by about 50%. Thus, in the rat the effect of 2% halothane upon metabolic rate is comparable to that observed in barbiturate anaesthesia.

Changes in CO2 responsiveness and in autoregulation of the cerebral circulation during and after halothane-induced hypotension

CO2 responsiveness of the cerebral circulation has been measured in baboons before, during, and after halothane-induced hypotension. At a systolic blood pressure (BP) of 60 mmHg, C02 responsiveness was abolished, but was maintained at higher levels of BP. After hypotension, CO2 responsiveness returned to control values. Autoregulation to BP increases induced by intravenous noradrenaline was impaired when cerebral perfusion pressure during the hypotensive period had been below 30-40 mmHg. It is concluded that at levels of halothane-induced hypotension commonly employed clinically, CO2 responsiveness of the cerebral circulation may be absent. The return of CO2 responsiveness in the post-hypotensive phase argues in favour of controlled hyperventilation after neurosurgery which has involved induced hypotension.

Effects of decreasing arterial blood pressure on cerebral blood flow in the baboon. Influence of the sympathetic nervous system

The influence of the sympathetic nervous system on the cerebral circulatory response to graded reductions in mean arterial blood pressure was studied in anesthetized baboons. Cerebral blood flow was measured by the 133Xe clearance method, and arterial blood pressure was decreased by controlled hemorrhage. In normal baboons, the constancy of cerebral blood flow was maintained until mean arterial blood pressure was approximately 65% of the base-line value; thereafter, cerebral blood flow decreased when arterial blood pressure was reduced. Superior cervical sympathectomy of 2-3 weeks duration did not affect the normal response. In contrast, both acute surgical sympathectomy (cervical trunk division) and alpha-receptor blockade (1.5 mg/kg of phenoxybenzamine) enhanced the maintenance of cerebral blood flow in the face of hemorrhagic hypotension in that cerebral blood flow did not decrease until mean arterial blood pressure was approximately 35% of the base-line value. The results indicate that the sympathetic nervous system is not involved in the maintenance of cerebral blood flow in the face of a fall in arterial blood pressure. Indeed, the implication is that the sympathicoadrenal discharge accompanying hemorrhagic hypotension is detrimental to, rather than responsible for, cerebral autoregulation.

Vasogenic edema following acute and chronic spinal cord compression in the dog

The T-13 spinal cord segment of dogs was compressed both acutely and chronically by means of a balloon catheter. The vascular permeability to protein was assessed using Evans blue albumin (EBA), and the dorsal column evoked potential recorded to monitor conduction failure. With acute compression sufficient to cause conduction failure there was a marked leakage of EBA from the intermediate gray matter, which spread into the dorsolateral white matter. The degree of edema was similar whether the compression was maintained or released. Chronic compression maintained over 4 to 5 hours did not increase vascular permeability, but following release of compression leakage of EBA occurred in the same cord locations observed with leakage from acute compressions. This increased permeability following release of chronic compression may result from reactive hyperemia. Dorsal column conduction returned after the release of both acute and chronic compression. The extravasated EBA was present both in the extracellular space and within cells. The results and their clinical application are discussed.