Predicting cerebral blood flow response to orthostatic stress from resting dynamics: effects of healthy aging

The complexity of cerebral blood flow regulation: the interaction of posture and vasomotor reactivity

Arterial carbon dioxide ([Formula: see text]) and posture influence the middle (MCAv) and posterior (PCAv) cerebral artery blood velocities, but there is paucity of data about their interaction and need for an integrated model of their effects, including dynamic cerebral autoregulation (dCA). In 22 participants (11 males, age 30.2 ± 14.3 yr), blood pressure (BP, Finometer), dominant MCAv and nondominant PCAv (transcranial Doppler ultrasound), end-tidal CO2 (EtCO2, capnography), and heart rate (HR, ECG) were recorded continuously. Two recordings (R) were taken when the participant was supine (R1, R2), two taken when the participant was sitting (R3, R4), and two taken when the participant was standing (R5, R6). R1, R3, and R5 consisted of 3 min of 5% CO2 through a mask and R2, R4, and R6 consisted of 3 min of paced hyperventilation. The effects of [Formula: see text] were expressed with a logistic curve model (LCM) for each parameter. dCA was expressed by the autoregulation index (ARI), derived by transfer function analysis. Standing shifted LCM to the left for MCAv (P < 0.001), PCAv (P < 0.001), BP (P = 0.03), and ARI (P = 0.001); downward for MCAv and PCAv (both P < 0.001), and upward for HR (P < 0.001). For BP, LCM was shifted downward by sitting and standing (P = 0.024). For ARI, the hypercapnic range of LCM was shifted upward during standing (P < 0.001). A more complete mapping of the combined effects of posture and arterial CO2 on the cerebral circulation and peripheral variables can be obtained with the LCM over a broad physiological range of EtCO2 values.NEW & NOTEWORTHY Data from supine, sitting, and standing postures were measured. Modeling the data with logistic curves to express the effects of CO2 reactivity on middle cerebral artery blood velocity (MCAv), posterior cerebral artery blood velocity (PCAv), heart rate, blood pressure (BP), and the autoregulation index (ARI), provided a more comprehensive approach to study the interaction of arterial CO2 with posture than in previous studies. Above all, shifts of the logistic curve model with changes in posture have shown interactions with [Formula: see text] that have not been previously demonstrated.

The acute influence of amateur boxing on dynamic cerebral autoregulation and cerebrovascular reactivity to carbon dioxide

PURPOSE

The purpose of this study was to investigate the acute effect of head impacts, sustained over the course of three rounds of amateur boxing, on indices of cerebrovascular function.

METHODS

Eighteen university amateur boxers (six female) completed three experimental trials in a randomised order; (1) three rounds of boxing (BOX), (2) an equivalent bout of pad boxing (where no blows to the head were sustained; PAD), and (3) a time-matched seated control trial (CON). Indices of cerebrovascular function were determined immediately before and 45 min after each trial. Specifically, dynamic cerebral autoregulation (dCA) was determined by considering the relationship between changes in cerebral blood velocity and mean arterial pressure during 5 min of squat-stand manoeuvres at 0.05 and 0.10 Hz. Cerebrovascular reactivity was determined using serial breath holding and hyperventilation attempts.

RESULTS

Participants received an average of 40 ± 16 punches to the head during the BOX trial. Diastolic, mean and systolic dCA phase during squat stand manoeuvres at 0.05 Hz was lower after BOX compared to pre BOX (P ≤ 0.02, effect size (d) ≥ 0.74). No other alterations in dCA outcomes were observed at 0.05 or 0.10 Hz. The number of head impacts received during the BOX trial was associated with the change in systolic phase (r = 0.50, P = 0.03). No differences in cerebrovascular reactivity to breath holding or hyperventilation were observed.

CONCLUSIONS

A typical bout of amateur boxing (i.e., three rounds) can subtly alter cerebral pressure-flow dynamics, and the magnitude of this change may be related to head impact exposure.

Resistance exercise acutely elevates dynamic cerebral autoregulation gain

Dynamic cerebral autoregulation (dCA) describes the regulation of cerebral blood flow (CBF) in response to fluctuations in systemic blood pressure (BP). Heavy resistance exercise is known to induce large transient elevations in BP, which are translated into perturbations of CBF, and may alter dCA in the immediate aftermath. This study aimed to better quantify the time course of any acute alterations in dCA after resistance exercise. Following familiarisation to all procedures, 22 (14 male) healthy young adults (22 ± 2 years) completed an experimental trial and resting control trial, in a counterbalanced order. Repeated squat-stand manoeuvres (SSM) at 0.05 and 0.10 Hz were used to quantify dCA before, and 10 and 45 min after four sets of ten repetition back squats at 70% of one repetition maximum, or time matched seated rest (control). Diastolic, mean and systolic dCA were quantified by transfer function analysis of BP (finger plethysmography) and middle cerebral artery blood velocity (transcranial Doppler ultrasound). Mean gain (p = 0.02; d = 0.36) systolic gain (p = 0.01; d = 0.55), mean normalised gain (p = 0.02; d = 0.28) and systolic normalised gain (p = 0.01; d = 0.67) were significantly elevated above baseline during 0.10 Hz SSM 10-min post resistance exercise. This alteration was not present 45 min post-exercise, and dCA indices were never altered during SSM at 0.05 Hz. dCA metrics were acutely altered 10 min post resistance exercise at the 0.10 Hz frequency only, which indicate changes in the sympathetic regulation of CBF. These alterations recovered 45 min post-exercise.

Two-Tiered Response of Cardiorespiratory-Cerebrovascular Network to Orthostatic Challenge

Dynamic interdependencies within and between physiological systems and subsystems are key for homeostatic mechanisms to establish an optimal state of the organism. These interactions mediate regulatory responses elicited by various perturbations, such as the high-pressure baroreflex and cerebral autoregulation, alleviating the impact of orthostatic stress on cerebral hemodynamics and oxygenation. The aim of this study was to evaluate the responsiveness of the cardiorespiratory-cerebrovascular networks by capturing linear and nonlinear interdependencies to postural changes. Ten young healthy adults participated in our study. Non-invasive measurements of arterial blood pressure (from that cardiac cycle durations were derived), breath-to-breath interval, cerebral blood flow velocity (BFV, recorded by transcranial Doppler sonography), and cerebral hemodynamics (HbT, total hemoglobin content monitored by near-infrared spectroscopy) were performed for 30-min in resting state, followed by a 1-min stand-up and a 1-min sit-down period. During preprocessing, noise was filtered and the contribution of arterial blood pressure was regressed from BFV and HbT signals. Cardiorespiratory-cerebrovascular networks were reconstructed by computing pair-wise Pearson-correlation or mutual information between the resampled signals to capture their linear and/or nonlinear interdependencies, respectively. The interdependencies between cardiac, respiratory, and cerebrovascular dynamics showed a marked weakening after standing up persisting throughout the sit-down period, which could mainly be attributed to strikingly attenuated nonlinear coupling. To summarize, we found that postural changes induced topological changes in the cardiorespiratory-cerebrovascular network. The dissolution of nonlinear networks suggests that the complexity of key homeostatic mechanisms maintaining cerebral hemodynamics and oxygenation is indeed sensitive to physiological perturbations such as orthostatic stress.

Body Position Affects Capillary Blood Flow Regulation Measured with Wearable Blood Flow Sensors

In this study we demonstrate what kind of relative alterations can be expected in average perfusion and blood flow oscillations during postural changes being measured in the skin of limbs and on the brow of the forehead by wearable laser Doppler flowmetry (LDF) sensors. The aims of the study were to evaluate the dynamics of cutaneous blood perfusion and the regulatory mechanisms of blood microcirculation in the areas of interest, and evaluate the possible significance of those effects for the diagnostics based on blood perfusion monitoring. The study involved 10 conditionally healthy volunteers (44 ± 12 years). Wearable laser Doppler flowmetry monitors were fixed at six points on the body: two devices were fixed on the forehead, on the brow; two were on the distal thirds of the right and left forearms; and two were on the distal thirds of the right and left lower legs. The protocol was used to record three body positions on the tilt table for orthostatic test for each volunteer in the following sequence: (a) supine body position; (b) upright body position (+75°); (c) tilted with the feet elevated above the head and the inclination of body axis of 15° (−15°, Trendelenburg position). Skin blood perfusion was recorded for 10 min in each body position, followed by the amplitude–frequency analysis of the registered signals using wavelet decomposition. The measurements were supplemented with the blood pressure and heart rate for every body position analysed. The results identified a statistically significant transformation in microcirculation parameters of the average level of skin blood perfusion and oscillations of amplitudes of neurogenic, myogenic and cardiac sensors caused by the postural changes. In paper, we present the analysis of microcirculation in the skin of the forehead, which for the first time was carried out in various positions of the body. The area is supplied by the internal carotid artery system and can be of particular interest for evaluation of the sufficiency of blood supply for the brain.

Vascular and haemodynamic issues of brain ageing

The population is ageing worldwide, thus increasing the burden of common age-related disorders to the individual, society and economy. Cerebrovascular diseases (stroke, dementia) contribute a significant proportion of this burden and are associated with high morbidity and mortality. Thus, understanding and promoting healthy vascular brain ageing are becoming an increasing priority for healthcare systems. In this review, we consider the effects of normal ageing on two major physiological processes responsible for vascular brain function: Cerebral autoregulation (CA) and neurovascular coupling (NVC). CA is the process by which the brain regulates cerebral blood flow (CBF) and protects against falls and surges in cerebral perfusion pressure, which risk hypoxic brain injury and pressure damage, respectively. In contrast, NVC is the process by which CBF is matched to cerebral metabolic activity, ensuring adequate local oxygenation and nutrient delivery for increased neuronal activity. Healthy ageing is associated with a number of key physiological adaptations in these processes to mitigate age-related functional and structural declines. Through multiple different paradigms assessing CA in healthy younger and older humans, generating conflicting findings, carbon dioxide studies in CA have provided the greatest understanding of intrinsic vascular anatomical factors that may mediate healthy ageing responses. In NVC, studies have found mixed results, with reduced, equivalent and increased activation of vascular responses to cognitive stimulation. In summary, vascular and haemodynamic changes occur in response to ageing and are important in distinguishing “normal” ageing from disease states and may help to develop effective therapeutic strategies to promote healthy brain ageing.

Does gradual change in head positioning affect cerebrovascular physiology?

We studied cerebral blood velocity (CBV), and associated hemodynamic parameters during gradual changes in head positioning in a nonstroke group. CBV (transcranial Doppler ultrasound), beat-to-beat blood pressure (BP, Finometer), and end-tidal carbon dioxide (ETCO2 , capnography) were recorded between lying flat (0°) and sitting up (30°) head positions, in 18 volunteers (10 female, mean age, 57 ± 16 years), at two visits (12 ± 8 days). A significant reduction was found between 5-min FLAT (0°) and 5-min SIT (30°) positions in CBV (visit 1: 4.5 ± 3.3%, P = 0.006; visit 2: 4.1 ± 3.5%, P = 0.003), critical closing pressure (CrCP; visit 1: 15.5 ± 14.0%, P = 0.0002; visit 2: 14.1 ± 7.8%, P = 0.009) and BP (visit 1: 8.3 ± 7.4%, P = 0.001; visit 2: 11.0 ± 11.3%, P < 0.001). For 5 min segments of data, the autoregulation index and other hemodynamic parameters did not show differences either due to head position or visit. For 30 sec time intervals, significant differences were observed in the following: (BP, P < 0.001; dominant hemisphere (DH) CBV, P < 0.005; nondominant hemisphere (NDH) CBV, P < 0.005; DH CrCP, P < 0.001; NDH CrCP, P < 0.001; DH resistance area product (RAP), P = 0.002; NDH RAP, P = 0.033). Significant static changes in BP, CBV and CrCP, and large transient changes in key hemodynamic parameters occur during 0° to 30°, and vice versa, with reproducible results. Further studies are needed following acute ischemic stroke to determine if a similar responses is present.

Functional vascular contributions to cognitive impairment and dementia: mechanisms and consequences of cerebral autoregulatory dysfunction, endothelial impairment, and neurovascular uncoupling in aging

Increasing evidence from epidemiological, clinical and experimental studies indicate that age-related cerebromicrovascular dysfunction and microcirculatory damage play critical roles in the pathogenesis of many types of dementia in the elderly, including Alzheimer's disease. Understanding and targeting the age-related pathophysiological mechanisms that underlie vascular contributions to cognitive impairment and dementia (VCID) are expected to have a major role in preserving brain health in older individuals. Maintenance of cerebral perfusion, protecting the microcirculation from high pressure-induced damage and moment-to-moment adjustment of regional oxygen and nutrient supply to changes in demand are prerequisites for the prevention of cerebral ischemia and neuronal dysfunction. This overview discusses age-related alterations in three main regulatory paradigms involved in the regulation of cerebral blood flow (CBF): cerebral autoregulation/myogenic constriction, endothelium-dependent vasomotor function, and neurovascular coupling responses responsible for functional hyperemia. The pathophysiological consequences of cerebral microvascular dysregulation in aging are explored, including blood-brain barrier disruption, neuroinflammation, exacerbation of neurodegeneration, development of cerebral microhemorrhages, microvascular rarefaction, and ischemic neuronal dysfunction and damage. Due to the widespread attention that VCID has captured in recent years, the evidence for the causal role of cerebral microvascular dysregulation in cognitive decline is critically examined.

Posture-related changes in brain functional connectivity as assessed by wavelet phase coherence of NIRS signals in elderly subjects

Postural instability and falls are commonly seen because of aging and motor disabilities. This study aims to assess the posture-related changes in brain functional connectivity by wavelet phase coherence (WPCO) of oxyhemoglobin concentration change (Δ[HbO2]) signals measured through near-infrared spectroscopy (NIRS) in elderly subjects. The NIRS signals were continuously recorded from the prefrontal cortex and sensorimotor cortical areas in 39 healthy elderly subjects and 22 young healthy subjects during 20min resting and 10min standing states. Eight connection types were obtained from the recorded brain areas. The WPCO were calculated in five frequency intervals in each channel pair as follows: I, 0.6-2Hz; II, 0.145-0.6Hz; III, 0.052-0.145Hz; IV, 0.021-0.052Hz; and V, 0.0095-0.021Hz. Results show that posture change and age significantly interacts with the right prefrontal cortex (PFC) and left sensorimotor cortex (SMC) connectivity in interval V (F=5.010, p=0.028). The left and right PFC connectivity in interval I, the left and right SMC connectivity in interval IV, and the connectivity in interval V, including right PFC and right SMC connectivity, left PFC and left SMC connectivity, and right PFC and left SMC connectivity, showed a significant difference between the Group Elderly and Group Young in response to posture change (p<0.05). This study provides new insight into the mechanism of posture control, and results may be useful in assessing the risk of postural instability in aged persons.

Assessing cerebral autoregulation via oscillatory lower body negative pressure and projection pursuit regression

The process by which cerebral perfusion is maintained constant over a wide range of systemic pressures is known as "cerebral autoregulation." Effective dampening of flow against pressure changes occurs over periods as short as ~15 sec and becomes progressively greater over longer time periods. Thus, slower changes in blood pressure are effectively blunted and faster changes or fluctuations pass through to cerebral blood flow relatively unaffected. The primary difficulty in characterizing the frequency dependence of cerebral autoregulation is the lack of prominent spontaneous fluctuations in arterial pressure around the frequencies of interest (less than ~0.07 Hz or ~15 sec). Oscillatory lower body negative pressure (OLBNP) can be employed to generate oscillations in central venous return that result in arterial pressure fluctuations at the frequency of OLBNP. Moreover, Projection Pursuit Regression (PPR) provides a nonparametric method to characterize nonlinear relations inherent in the system without a priori assumptions and reveals the characteristic non-linearity of cerebral autoregulation. OLBNP generates larger fluctuations in arterial pressure as the frequency of negative pressure oscillations become slower; however, fluctuations in cerebral blood flow become progressively lesser. Hence, the PPR shows an increasingly more prominent autoregulatory region at OLBNP frequencies of 0.05 Hz and below (20 sec cycles). The goal of this approach it to allow laboratory-based determination of the characteristic nonlinear relationship between pressure and cerebral flow and could provide unique insight to integrated cerebrovascular control as well as to physiological alterations underlying impaired cerebral autoregulation (e.g., after traumatic brain injury, stroke, etc.).

Relative contributions of sympathetic, cholinergic, and myogenic mechanisms to cerebral autoregulation

BACKGROUND AND PURPOSE

Prior work aimed at improving our understanding of human cerebral autoregulation has explored individual physiological mechanisms of autoregulation in isolation, but none has attempted to consolidate the individual roles of these mechanisms into a comprehensive model of the overall cerebral pressure-flow relationship.

METHODS

We retrospectively analyzed this relationship before and after pharmacological blockade of α-adrenergic-, muscarinic-, and calcium channel-mediated mechanisms in 43 healthy volunteers to determine the relative contributions of the sympathetic, cholinergic, and myogenic controllers to cerebral autoregulation. Projection pursuit regression was used to assess the effect of pharmacological blockade on the cerebral pressure-flow relationship. Subsequently, ANCOVA decomposition was used to determine the cumulative effect of these 3 mechanisms on cerebral autoregulation and whether they can fully explain it.

RESULTS

Sympathetic, cholinergic, and myogenic mechanisms together accounted for 62% of the cerebral pressure-flow relationship (P<0.05), with significant and distinct contributions from each of the 3 effectors. ANCOVA decomposition demonstrated that myogenic effectors were the largest determinant of the cerebral pressure-flow relationship, but their effect was outside of the autoregulatory region where neurogenic control appeared prepotent.

CONCLUSIONS

Our results suggest that myogenic effects occur outside the active region of autoregulation, whereas neurogenic influences are largely responsible for cerebral blood flow control within it. However, our model of cerebral autoregulation left 38% of the cerebral pressure-flow relationship unexplained, suggesting that there are other physiological mechanisms that contribute to cerebral autoregulation.

Assessment of dynamic cerebral autoregulation and cerebrovascular CO2 reactivity in ageing by measurements of cerebral blood flow and cortical oxygenation

With ageing, cerebral blood flow velocity (CBFV) decreases; however, to what extent dynamic cerebral autoregulation and cerebrovascular CO2 reactivity are influenced by ageing is unknown. The aim was to examine the dynamic responses of CBFV and cortical oxygenation to changes in blood pressure (BP) and arterial CO2 across different ages. Fifty-eight participants in three age groups were included, as follows: young (n = 20, 24 ± 2 years old), elderly (n = 20, 66 ± 1 years old), and older elderly (n = 18, 78 ± 3 years old). The CBFV was measured using transcranial Doppler ultrasound, simultaneously with oxyhaemoglobin (O2Hb) using near-infrared spectroscopy and beat-to-beat BP measurements using Finapres. Postural manoeuvres were performed to induce haemodynamic fluctuations. Cerebrovascular CO2 reactivity was tested with hyperventilation and CO2 inhalation. With age, CBFV decreased (young 59 ± 12 cm s(-1), elderly 48 ± 7 cm s(-1) and older elderly 42 ± 9 cm s(-1), P < 0.05) and cerebrovascular resistance increased (1.46 ± 0.58, 1.81 ± 0.36 and 1.98 ± 0.52 mmHg cm(-1) s(-1), respectively, P < 0.05). Normalized gain (autoregulatory damping) increased with age for BP-CBFV (0.88 ± 0.18, 1.31 ± 0.30 and 1.06 ± 0.34, respectively, P < 0.05) and CBFV-O2Hb (0.10 ± 0.09, 0.12 ± 0.04 and 0.17 ± 0.08, respectively, P < 0.05) during the repeated sit-stand manoeuvre at 0.05 Hz. Even though the absolute changes in CBFV and cerebrovascular resistance index during the cerebrovascular CO2 reactivity were higher in the young group, the percentage changes in CBFV, cerebrovascular resistance index and O2Hb were similar in all age groups. In conclusion, there was no decline in dynamic cerebral autoregulation and cerebrovascular CO2 reactivity with increasing age up to 86 years. Despite the decrease in cerebral blood flow velocity and increase in cerebrovascular resistance with advancing age, CBFV and cortical oxygenation were not compromised in these elderly humans during manoeuvres that mimic daily life activities.

Increasing pressure of external counterpulsation augments blood pressure but not cerebral blood flow velocity in ischemic stroke

External counterpulsation (ECP) is a noninvasive method used to augment cerebral perfusion but the optimal use of ECP in ischemic stroke has not been well documented. We aimed to investigate the effects of ECP treatment pressure on cerebral blood flow and blood pressure (BP). We recruited 38 ischemic stroke patients with large artery occlusive disease and 20 elderly controls. We commenced ECP treatment pressure at 150 mmHg and gradually increased to 187.5, 225 and 262.5 mmHg. Mean cerebral blood flow velocities (CBFV) of bilateral middle cerebral arteries and continuous beat-to-beat BP were recorded before ECP and during each pressure increment for 3 minutes. Patient CBFV data was analyzed based on whether it was ipsilateral or contralateral to the infarct. Mean BP significantly increased from baseline in both stroke and control groups after ECP commenced. BP increased in both groups following raised ECP pressure and reached maximum at 262.5 mmHg (patients 16.9% increase versus controls 16.52%). The ipsilateral CBFV of patients increased 5.15%, 4.35%, 4.55% and 3.52% from baseline under the four pressures, respectively. All were significantly higher than baseline but did not differ among different ECP pressures; contralateral CBFV changed likewise. Control CBFV did not increase under variable pressures of ECP. ECP did increase CBFV of our patients to a roughly equal degree regardless of ECP pressure. Among the four ECP pressures tested, we recommend 150 mmHg as the optimal treatment pressure for ischemic stroke due to higher risks of hypertension-related complications with higher pressures.

Integrative physiological and computational approaches to understand autonomic control of cerebral autoregulation

The brain requires steady delivery of oxygen and glucose, without which neurodegeneration occurs within minutes. Thus, the ability of the cerebral vasculature to maintain relatively steady blood flow in the face of changing systemic pressure, i.e. cerebral autoregulation, is critical to neurophysiological health. Although the study of autoregulation dates to the early 20th century, only the recent availability of cerebral blood flow measures with high temporal resolution has allowed rapid, beat-by-beat measurements to explore the characteristics and mechanisms of autoregulation. These explorations have been further enhanced by the ability to apply sophisticated computational approaches that exploit the large amounts of data that can be acquired. These advances have led to unique insights. For example, recent studies have revealed characteristic time scales wherein cerebral autoregulation is most active, as well as specific regions wherein autonomic mechanisms are prepotent. However, given that effective cerebral autoregulation against pressure fluctuations results in relatively unchanging flow despite changing pressure, estimating the pressure-flow relationship can be limited by the error inherent in computational models of autoregulatory function. This review focuses on the autonomic neural control of the cerebral vasculature in health and disease from an integrative physiological perspective. It also provides a critical overview of the current analytical approaches to understand cerebral autoregulation.

The role of myogenic mechanisms in human cerebrovascular regulation

Although myogenic mechanisms have been hypothesized to play a role in cerebrovascular regulation, previous data from both animals and humans have not provided an unequivocal answer. However, cerebral autoregulation is explicitly non-linear and most prior work relied on simple linear approaches for assessment, potentially missing important changes in autoregulatory characteristics. Therefore, we examined cerebral blood flow responses to augmented arterial pressure oscillations with and without calcium channel blockade (nicardipine) during blood pressure fluctuations (oscillatory lower body negative pressure, OLBNP) across a range of frequencies in 16 healthy subjects. Autoregulation was characterized via a robust non-linear method (projection pursuit regression, PPR). Blockade resulted in significant tachycardia, a modest but significant elevation in mean arterial pressure, and reductions in mean cerebral blood flow and end-tidal CO2 during OLBNP. The reductions in flow were directly related to the reductions in CO2 (r = 0.57). While linear cross-spectral analysis showed that the relationship between pressure-flow fluctuations was preserved after blockade, PPR showed that blockade significantly altered the non-linearity between pressure and flow, particularly at the slowest fluctuations. At 0.03 Hz, blockade reduced the range of pressure fluctuations that can be buffered (7.5 ± 1.0 vs. 3.7 ± 0.8 mmHg) while increasing the autoregulatory slope (0.10 ± 0.05 vs. 0.24 ± 0.08 cm s(-1) mmHg(-1)). Furthermore, the same rate of change in pressure elicited a change in flow more than twice as large as at baseline. Thus, our results show that myogenic mechanisms play a significant role in cerebrovascular regulation but this may not be appreciated without adequately characterizing the non-linearities inherent in cerebrovascular regulation.

Reliability, asymmetry, and age influence on dynamic cerebral autoregulation measured by spontaneous fluctuations of blood pressure and cerebral blood flow velocities in healthy individuals

BACKGROUND

Cerebral autoregulation (CA) enables the brain to maintain stable cerebral blood flow (CBF). CA can be assessed noninvasively by determining correlations between CBF velocity (CBFV) and spontaneous changes in blood pressure. Postrecording signal analysis methods have included both frequency- and time-domain methods. However, the test-retest reliability, cross-validation, and determination of normal values have not been adequately established.

METHODS

In 53 healthy volunteers, a transfer function analysis was applied to calculate phase shift (PS) and gain in the low frequency range (.06-.12 Hz) where CA is most apparent. Correlation analysis was used to derive mean velocity index (Mx). Intraclass correlation and bivariate correlation coefficients were applied to assess asymmetry, cross-validity, and test-retest results: The bihemispheric average PS, gain, and Mx means were 45.99+/-14.24°, .62+/-.38 cm/second/mmHg, and .41+/-.13, respectively. Gain exhibited a difference by age (P = .03). PS, gain, and Mx values showed excellent interhemispheric correlation (r > .8; P < .001). PS and gain showed good reliability (R ICC = .632, L ICC = .576; P < .001). PS and Mx showed fair correlation (r = -.37; P < .001).

CONCLUSIONS

CA parameters obtained by time- and frequency-domain methods correlate well, and show good interhemispheric and test-retest reliability. Group means from healthy controls may provide adequate norms for determining abnormal CA in cerebrovascular patients.

Short-term aerobic exercise reduces nitroglycerin-induced orthostatic intolerance in older adults with type 2 diabetes

AIMS/HYPOTHESIS

Older adults are at a high risk for syncope due to orthostatic intolerance (OI), and this risk increases with comorbid type 2 diabetes and vasoactive medications. Despite many benefits, previous investigations have shown worsening OI with aerobic training. We examined whether aerobic exercise reduced OI in older adults with type 2 diabetes who were given a short-acting vasoactive agent (nitroglycerin).

METHODS

Forty older adults (25 males and 15 females, mean age 71.4 ± 0.7 years, ranging in age from 65 to 83 years) with type 2 diabetes were recruited. Subjects were randomized to each of 2 groups: an aerobic group (3 months of vigorous aerobic exercise) and a nonaerobic (no aerobic exercise) group. Exercise sessions were supervised by a certified exercise trainer 3 times per week. After being given 400 μg of sublingual nitroglycerin, each subject was placed in a 70° head-up tilt for 30 minutes.

RESULTS

When the 2 groups were compared using a Cox proportional hazards model, tilt table tolerance was significantly better in the aerobic group as compared to in the nonaerobic group (χ(2)(MC) = 7.271, P = 0.007).

CONCLUSIONS

Our findings indicate that a relatively short aerobic exercise intervention can improve postnitroglycerin orthostatic tolerance in older adults with type 2 diabetes.

Dynamic cerebral autoregulation in the old using a repeated sit-stand maneuver

The aim of this study was to assess the feasibility and reproducibility of a simple and nonobtrusive repeated sit-stand maneuver to assess cerebral autoregulation (CA) in healthy old subjects >70 years. In 27 subjects aged 76 (SD 4) years, we continuously measured blood pressure using photoplethysmography and cerebral blood flow velocity in the middle cerebral artery (transcranial Doppler ultrasonography) during 5 min of sitting rest and again during repeated sit-stand maneuvers at 10 s (0.05 Hz) and 5 s (0.1 Hz) intervals. In 11 randomly selected subjects, these measurements were repeated after 3 months. Both maneuvers induced substantial periodic oscillations in pressure and flow. For example, the maneuvers at 0.05 Hz increased the power spectral density (magnitude) of blood pressure and cerebral blood flow velocity oscillations with 16.3 (mm Hg)(2) and 14.5 (cm/s)(2), respectively (p<0.001). These larger oscillations led to an increase in transfer function coherence compared with spontaneous oscillations from 0.46 to 0.60 for 0.05 Hz maneuvers and from 0.56 to 0.76 for 0.1 Hz maneuvers (p<0.01), allowing for more confident assessment of CA through transfer function phase and gain. This increased coherence was not associated with improved reproducibility however. In conclusion, we were able to investigate CA in old patients using these repeated sit-stand maneuvers, which, compared with spontaneous oscillations, produced a stronger and more clinically relevant hemodynamic challenge for CA.

The effects of body mass index on cerebral blood flow velocity

OBJECTIVE

Obesity is a risk factor for cerebrovascular disease. We aimed to determine the effects of high body mass index (BMI) on cerebral blood flow regulation in patients with type-2 diabetes mellitus, hypertension, and stroke.

METHODS

We analyzed data from 90 controls, 30 diabetics, 45 hypertensives, and 32 ischemic stroke patients who underwent transcranial Doppler for evaluation of blood flow velocities (BFV) in the middle cerebral arteries (MCA) and cerebrovascular resistance (CVR) during supine rest and head-up tilt. This study was a cross-sectional analysis. We used a structural equation multiple indicators modeling to determine the effects of BMI and other background variables (age, sex, race, smoking, alcohol use, and systolic blood pressure) on cerebral BFV.

RESULTS

Higher BMI (P = 0.02) and age (P = 0.004) were associated with lower mean BFV during baseline, independent of diagnosis of diabetes mellitus, hypertension or stroke, and after adjusting for all background variables and vessel diameters. Men, especially those with stroke, had a lower mean BFV than women (P = 0.01). CVR increased with BMI (P = 0.001) at baseline and during head-up tilt (P = 0.02), and was elevated in obese subjects (P = 0.004) compared to normal weight subjects across all groups.

INTERPRETATION

High BMI is associated with a reduction in cerebral BFV and increased CVR. These findings indicate that obesity can adversely affect cerebral blood flow and resistance in the cerebrovascular bed, independent of diagnosis of type-2 diabetes, hypertension or stroke. Obesity may contribute to cerebromicrovascular disease, and affect clinical functional outcomes of the older population.

Cerebral autoregulation: an overview of current concepts and methodology with special focus on the elderly

Cerebral autoregulation (CA) refers to the properties of the brain vascular bed to maintain cerebral perfusion despite changes in blood pressure (BP). Whereas classic studies have assessed CA during changes in BP that have a gradual onset, dynamic studies quantify the fast modifications in cerebral blood flow (CBF) in relation to rapid alterations in BP. There is a lack of standardization in the assessment of dynamic CA. This review provides an overview of the methods that have been applied, with special focus on the elderly. We will discuss the relative merits and shortcomings of these methods with regard to the aged population. Furthermore, we summarize the effects of variability in BP on CBF in older people. Of the various dynamic assessments of CA, a single sit-to-stand procedure is a feasible and physiologic method in the elderly. The collection of spontaneous beat-to-beat changes in BP and CBF allows estimation of CA using the technique of transfer function analysis. A thorough search of the literature yielded eight studies that have measured dynamic CA in the elderly aged <75 years. Regardless of the methods used, it was concluded from these studies that CA was preserved in this population.

Physiologic aspects of aging: impact on cancer management and decision making, part II

In this second article of our two-part review, we focus on age-associated physiologic changes involving the nervous, endocrine, hematologic, immune, and musculoskeletal systems, with close attention to the interconnected nature of these systems. There is a well-known connection between the neuroendocrine and immune systems via the hypothalamic-pituitary-adrenal axis and via interaction by means of cytokines, hormones, and neurotransmitters. These changes may lead to a loss of integration and resiliency with age, thus decreasing the ability of the elderly patient with cancer to adapt to stressful circumstances. Prominent changes include decline in memory and cognition, and increased susceptibility to peripheral neuropathy. Hematologic and immune changes like reduced bone marrow reserve and increased susceptibility to infections have far reaching implications for cancer care in the elderly. Gradual decline in hormone levels, and changes in muscle and body composition, can lead to functional decline and frailty. Use of the clinical interventions suggested in this article, along with an appreciation of the interplay of these age-related physiologic changes and their consequences, allows oncology professionals to customize therapy and minimize side effects in the geriatric oncology patient.

Cross-correlation of instantaneous phase increments in pressure-flow fluctuations: applications to cerebral autoregulation

We investigate the relationship between the blood flow velocities (BFV) in the middle cerebral arteries and beat-to-beat blood pressure (BP) recorded from a finger in healthy and post-stroke subjects during the quasisteady state after perturbation for four different physiologic conditions: supine rest, head-up tilt, hyperventilation, and CO2 rebreathing in upright position. To evaluate whether instantaneous BP changes in the steady state are coupled with instantaneous changes in the BFV, we compare dynamical patterns in the instantaneous phases of these signals, obtained from the Hilbert transform, as a function of time. We find that in post-stroke subjects the instantaneous phase increments of BP and BFV exhibit well-pronounced patterns that remain stable in time for all four physiologic conditions, while in healthy subjects these patterns are different, less pronounced, and more variable. We propose an approach based on the cross-correlation of the instantaneous phase increments to quantify the coupling between BP and BFV signals. We find that the maximum correlation strength is different for the two groups and for the different conditions. For healthy subjects the amplitude of the cross-correlation between the instantaneous phase increments of BP and BFV is small and attenuates within 3-5 heartbeats. In contrast, for post-stroke subjects, this amplitude is significantly larger and cross-correlations persist up to 20 heartbeats. Further, we show that the instantaneous phase increments of BP and BFV are cross-correlated even within a single heartbeat cycle. We compare the results of our approach with three complementary methods: direct BP-BFV cross-correlation, transfer function analysis, and phase synchronization analysis. Our findings provide insight into the mechanism of cerebral vascular control in healthy subjects, suggesting that this control mechanism may involve rapid adjustments (within a heartbeat) of the cerebral vessels, so that BFV remains steady in response to changes in peripheral BP.

Cerebral pressure-flow relations in hypertensive elderly humans: transfer gain in different frequency domains

The dynamics of the cerebral vascular response to blood pressure changes in hypertensive humans is poorly understood. Because cerebral blood flow is dependent on adequate perfusion pressure, it is important to understand the effect of hypertension on the transfer of pressure to flow in the cerebrovascular system of elderly people. Therefore, we examined the effect of spontaneous and induced blood pressure changes on beat-to-beat and within-beat cerebral blood flow in three groups of elderly people: normotensive, controlled hypertensive, and uncontrolled hypertensive subjects. Cerebral blood flow velocity (transcranial Doppler), blood pressure (Finapres), heart rate, and end-tidal CO(2) were measured during the transition from a sit to stand position. Transfer function gains relating blood pressure to cerebral blood flow velocity were assessed during steady-state sitting and standing. Cerebral blood flow regulation was preserved in all three groups by using changes in cerebrovascular resistance, transfer function gains, and the autoregulatory index as indexes of cerebral autoregulation. Hypertensive subjects demonstrated better attenuation of cerebral blood flow fluctuations in response to blood pressure changes both within the beat (i.e., lower gain at the cardiac frequency) and in the low-frequency range (autoregulatory, 0.03-0.07 Hz). Despite a better pressure autoregulatory response, hypertensive subjects demonstrated reduced reactivity to CO(2). Thus otherwise healthy hypertensive elderly subjects, whether controlled or uncontrolled with antihypertensive medication, retain the ability to maintain cerebral blood flow in the face of acute changes in perfusion pressure. Pressure regulation of cerebral blood flow is unrelated to cerebrovascular reactivity to CO(2).

EEG dynamics in patients with Alzheimer's disease

Alzheimer's disease (AD) is the most common neurodegenerative disorder characterized by cognitive and intellectual deficits and behavior disturbance. The electroencephalogram (EEG) has been used as a tool for diagnosing AD for several decades. The hallmark of EEG abnormalities in AD patients is a shift of the power spectrum to lower frequencies and a decrease in coherence of fast rhythms. These abnormalities are thought to be associated with functional disconnections among cortical areas resulting from death of cortical neurons, axonal pathology, cholinergic deficits, etc. This article reviews main findings of EEG abnormalities in AD patients obtained from conventional spectral analysis and nonlinear dynamical methods. In particular, nonlinear alterations in the EEG of AD patients, i.e. a decreased complexity of EEG patterns and reduced information transmission among cortical areas, and their clinical implications are discussed. For future studies, improvement of the accuracy of differential diagnosis and early detection of AD based on multimodal approaches, longitudinal studies on nonlinear dynamics of the EEG, drug effects on the EEG dynamics, and linear and nonlinear functional connectivity among cortical regions in AD are proposed to be investigated. EEG abnormalities of AD patients are characterized by slowed mean frequency, less complex activity, and reduced coherences among cortical regions. These abnormalities suggest that the EEG has utility as a valuable tool for differential and early diagnosis of AD.

Spectral indices of human cerebral blood flow control: responses to augmented blood pressure oscillations

We set out to fully examine the frequency domain relationship between arterial pressure and cerebral blood flow. Oscillatory lower body negative pressure (OLBNP) was used to create consistent blood pressure oscillations of varying frequency and amplitude to rigorously test for a frequency- and/or amplitude-dependent relationship between arterial pressure and cerebral flow. We also examined the predictions from OLBNP data for the cerebral flow response to the stepwise drop in pressure subsequent to deflation of ischaemic thigh cuffs. We measured spectral powers, cross-spectral coherence, and transfer function gains and phases in arterial pressure and cerebral flow during three amplitudes (0, 20, and 40 mmHg) and three frequencies (0.10, 0.05, and 0.03 Hz) of OLBNP in nine healthy young volunteers. Pressure fluctuations were directly related to OLBNP amplitude and inversely to OLBNP frequency. Although cerebral flow oscillations were increased, they did not demonstrate the same frequency dependence seen in pressure oscillations. The overall pattern of the pressure-flow relation was of decreasing coherence and gain and increasing phase with decreasing frequency, characteristic of a high-pass filter. Coherence between pressure and flow was increased at all frequencies by OLBNP, but was still significantly lower at frequencies below 0.07 Hz despite the augmented pressure input. In addition, predictions of thigh cuff data from spectral estimates were extremely inconsistent and highly variable, suggesting that cerebral autoregulation is a frequency-dependent mechanism that may not be fully characterized by linear methods.

Autonomic neural control of dynamic cerebral autoregulation in humans

BACKGROUND

The purpose of the present study was to determine the role of autonomic neural control of dynamic cerebral autoregulation in humans.

METHODS AND RESULTS

We measured arterial pressure and cerebral blood flow (CBF) velocity in 12 healthy subjects (aged 29+/-6 years) before and after ganglion blockade with trimethaphan. CBF velocity was measured in the middle cerebral artery using transcranial Doppler. The magnitude of spontaneous changes in mean blood pressure and CBF velocity were quantified by spectral analysis. The transfer function gain, phase, and coherence between these variables were estimated to quantify dynamic cerebral autoregulation. After ganglion blockade, systolic and pulse pressure decreased significantly by 13% and 26%, respectively. CBF velocity decreased by 6% (P<0.05). In the very low frequency range (0.02 to 0.07 Hz), mean blood pressure variability decreased significantly (by 82%), while CBF velocity variability persisted. Thus, transfer function gain increased by 81%. In addition, the phase lead of CBF velocity to arterial pressure diminished. These changes in transfer function gain and phase persisted despite restoration of arterial pressure by infusion of phenylephrine and normalization of mean blood pressure variability by oscillatory lower body negative pressure.

CONCLUSIONS

These data suggest that dynamic cerebral autoregulation is altered by ganglion blockade. We speculate that autonomic neural control of the cerebral circulation is tonically active and likely plays a significant role in the regulation of beat-to-beat CBF in humans.

Dynamics of stability: the physiologic basis of functional health and frailty

Under basal resting conditions most healthy physiologic systems demonstrate highly irregular, complex dynamics that represent interacting regulatory processes operating over multiple time scales. These processes prime the organism for an adaptive response, making it ready and able to react to sudden physiologic stresses. When the organism is perturbed or deviates from a given set of boundary conditions, most physiologic systems evoke closed-loop responses that operate over relatively short periods of time to restore the organism to equilibrium. This transiently alters the dynamics to a less complex, dominant response mode, which is denoted "reactive tuning." Aging and disease are associated with a loss of complexity in resting dynamics and maladaptive responses to perturbations. These alterations in the dynamics of physiologic systems lead to functional decline and frailty. Nonlinear mathematical techniques that quantify physiologic dynamics may predict the onset of frailty, and interventions aimed toward restoring healthy dynamics may prevent functional decline.