Evidence for the direct effect of adrenergic drugs on the cerebral vascular bed of the unanesthetized goat

The cerebrovascular response to norepinephrine: A scoping systematic review of the animal and human literature

Intravenous norepinephrine (NE) is utilized commonly in critical care for cardiovascular support. NE's impact on cerebrovasculature is unclear and may carry important implications during states of critical neurological illness. The aim of the study was to perform a scoping review of the literature on the cerebrovascular/cerebral blood flow (CBF) effects of NE. A search of MEDLINE, BIOSIS, EMBASE, Global Health, SCOPUS, and Cochrane Library from inception to December 2019 was performed. All manuscripts pertaining to the administration of NE, in which the impact on CBF/cerebral vasculature was recorded, were included. We identified 62 animal studies and 26 human studies. Overall, there was a trend to a direct vasoconstriction effect of NE on the cerebral vasculature, with conflicting studies having demonstrated both increases and decreases in regional CBF (rCBF) or global CBF. Healthy animals and those undergoing cardiopulmonary resuscitation demonstrated a dose-dependent increase in CBF with NE administration. However, animal models and human patients with acquired brain injury had varied responses in CBF to NE administration. The animal models indicate an increase in cerebral vasoconstriction with NE administration through the alpha receptors in vessels. Global and rCBF during the injection of NE displays a wide variation depending on treatment and model/patient.

Effects of dobutamine and phenylephrine on cerebral perfusion in patients undergoing cerebral bypass surgery: a randomised crossover trial

Background

Patients undergoing cerebral bypass surgery are prone to cerebral hypoperfusion. Currently, arterial blood pressure is often increased with vasopressors to prevent cerebral ischaemia. However, this might cause vasoconstriction of the graft and cerebral vasculature and decrease perfusion. We hypothesised that cardiac output, rather than arterial blood pressure, is essential for adequate perfusion and aimed to determine whether dobutamine administration resulted in greater graft perfusion than phenylephrine administration.

Methods

This randomised crossover study included 10 adult patients undergoing cerebral bypass surgery. Intraoperatively, patients randomly and sequentially received dobutamine to increase cardiac index or phenylephrine to increase mean arterial pressure (MAP). An increase of >10% in cardiac index or >10% in MAP was targeted, respectively. Before both interventions, a reference phase was implemented. The primary outcome was the absolute difference in graft flow between the reference and intervention phase. We compared the absolute flow difference between each intervention and constructed a random-effect linear regression model to explore treatment and carry-over effects.

Results

Graft flow increased with a median of 4.1 (inter-quartile range [IQR], 1.7–12.0] ml min⁻¹) after dobutamine administration and 3.6 [IQR, 1.3–7.8] ml min⁻¹ after phenylephrine administration (difference –0.6 ml min⁻¹; 95% confidence interval [CI], –14.5 to 5.3; P=0.441). There was no treatment effect (0.9 ml min⁻¹; 95% CI, 0.0–20.1; P=0.944) and no carry-over effect.

Conclusions

Both dobutamine and phenylephrine increased graft flow during cerebral bypass surgery, without a preference for one method over the other.

Clinical trial registration

Netherlands Trial Register, NL7077 (https://www.trialregister.nl/trial/7077).

Effect of cold face stimulation on cerebral blood flow in humans

BACKGROUND AND PURPOSE

In humans, activation of the diving reflex by a cold stimulus to the face results in bradycardia, peripheral vasoconstriction and an increase in blood pressure. However, responses of the cerebral blood flow have not yet been evaluated. We undertook this study to assess the effect of cold face stimulation on the cerebral circulation in humans.

METHODS

Seventeen healthy volunteers, aged 27+/-5 years were evaluated during application of a cold stimulus (0 degrees C) to the forehead for 60s. We continuously monitored mean arterial pressure (MAP), mean flow velocity (MFV) of the middle cerebral artery, cardiac output, skin blood flow, heart rate and end-tidal CO2. Total peripheral resistance (TPR) was calculated as MAP divided by cardiac output. Cerebrovascular resistance index (CVRi) was calculated as MAP divided by MFV.

RESULTS

Cold face stimulation did not significantly affect cardiac output but resulted in significant decreases in heart rate and skin blood flow and an increase in MAP. MFV in the mid-cerebral artery showed a slight, but significant increase. The maximum increase in CVRi (14.2+/-11.4%) was significantly (P<0.01) less than the maximum increase in TPR (23.9+/-5.7%). End-tidal CO2 did not change significantly during the cold stimulation.

CONCLUSIONS

In contrast to other sympathetic stimulations (e.g. lower body negative pressure), facial cooling results in an increase in cerebral blood flow. The amount of cerebral vasoconstriction was less than the amount of total peripheral vasoconstriction. These results suggest that although there is some constriction of the cerebral resistance vessels during cold face stimulation, cerebral perfusion was maintained, possibly by opposing parasympathetic activation.

Adrenergic vasoconstrictor activity in the cerebral circulation after inhibition of nitric oxide synthesis in conscious goats

The interaction between nitric oxide (NO) and adrenergic activity in the cerebral circulation was studied using conscious goats, where blood flow to one brain hemisphere (cerebral blood flow) was electromagnetically measured, and the effects of phentolamine and hexamethonium on cerebrovascular resistance were evaluated before (control) and after inhibition of NO synthesis with NW-nitro-L-arginine methyl ester (L-NAME). L-NAME (12 goats, 40 mg kg(-1) administered i.v.) reduced cerebral blood flow from 62 +/- 3 to 44 +/- 2 ml min(-1), increased mean systemic arterial pressure from 100 +/- 3 to 126 +/- 4 mm Hg, decreased heart rate from 79 +/- 5 to 50 +/- 4 beats min(-1) and increased cerebrovascular resistance from 1.63 +/- 0.08 to 2.91 +/- 0.016 mm Hg ml(-1)min(-1) (all P < 0.01). These hemodynamic variables normalized 48-72 h after L-NAME administration. Phentolamine (six goats, 1 mg), injected into the cerebral circulation. increased cerebral blood flow without changing systenic arterial pressure, but its cerebrovascular effects were augmented for about 24 h after L-NAME. The decrements in cerebrovascular resistance induced by phentolamine, in mm Hg ml(-1) min(-1), were: under control, 0.42 +/- 0.05; immediately after L-NAME, 1.38 +/- 0.09 (P < 0.01 compared with control); by about 24 h after L-NAME, 0.71 +/- 0.09 (P < 0.05 compared with control); and by about 48 h after L-NAME, 0.40 +/- 0.07 (P > 0.05 compared with control). Hexamethonium (six goats, 0.5-1 mg kg(-1) min(-1) i.v.) decreased mean systemic arterial pressure to about 75 mm Hg and caused tachycardia similarly before and after L-NAME, but the decrements in cerebrovascular resistance were augmented for about 24 h after L-NAME. The decrements in cerebrovascular resistance induced by hexamethonium, in mm Hg ml(-1).min(-1), were: under control. 0.61 +/- 0.09, immediately after L-NAME, 1.33 +/- 0.16 (P < 0.01 compared with control); by about 24 h after L-NAME, 1.18 +/- 0.10 (P < 0.01 compared with control): and by about 48 h after L-NAME, 0.99 +/- 0.10 (P > 0.05 compared with control). Therefore, these results suggest that adrenergic vasoconstrictor tone in cerebral vasculature may be augmented after inhibition of NO synthesis, and that this increment may contribute to the reduction of cerebral blood flow after inhibition of NO formation.

Role of nitric oxide in the cerebral circulation during hypotension after hemorrhage, ganglionic blockade and diazoxide in awake goats

The role of nitric oxide in cerebrovascular response to hypotension was analyzed by evaluating the changes in cerebrovascular resistance after inhibition of nitric oxide synthesis with Nw-nitro-L-arginine methyl ester (L-NAME) during three types of hypotension in conscious goats. Blood flow to one brain hemisphere was electromagnetically measured, hypotension was induced by controlled bleeding, and by i.v. administration of hexametonium (ganglionic blocker) or of diazoxide (vasodilator drug), and L-NAME was injected by i.v. route (35 mg kg-1). Under control conditions (13 goats), L-NAME increased arterial pressure from 98 +/- 3 to 123 +/- 4 mmHg and decreased cerebral blood flow from 65 +/- 3 to 40 +/- 3 ml min-1 (all P < 0.001); cerebrovascular resistance increased from 1.52 +/- 0.04 to 3.09 +/- 0.013 mmHg ml-1 min-1 (P < 0.01) (delta = 1.59 +/- 0.12 mmHg ml-1 min-1). After bleeding (five goats), mean arterial pressure decreased to 60 +/- 4 mmHg and cerebral blood flow decreased to 37 +/- 4 ml min-1 (all P < 0.01); cerebrovascular resistance did not change (1.56 +/- 0.14 vs. 1.54 +/- 0.12 mmHg ml-1 min-1, P > 0.05). During this hypotension, L-NAME increased arterial pressure to reach the normotensive values an did not affect the hypotensive values for cerebral blood flow; cerebrovascular resistance increased from the hypotensive values to 2.91 +/- 0.19 mmHg ml-1 min-1 (P < 0.01) (delta = 1.37 +/- 0.16 mmHg ml-1 min-1), and this increment is comparable to that under control conditions (P > 0.05). Ganglionic blockade (six goats) decreased arterial pressure to 67 +/- 2 mmHg) and did not affect significantly cerebral blood flow; cerebrovascular resistance decreased from 1.71 +/- 0.11 to 1.05 +/- 0.09 mmHg ml-1 min-1 (P < 0.01). During this hypotension, L-NAME increased arterial pressure to 103 +/- 6 mmHg (P < 0.001), and did not affect cerebral blood flow; cerebrovascular resistance increased from the hypotensive values to 1.68 +/- 0.18 mmHg ml-1 min-1 (P < 0.01) (delta = 0.63 +/- 0.10 mmHg ml-1 min-1), and this increment was lower than under control conditions (P < 0.01). Diazoxide (six goats) decreased arterial pressure to 69 +/- 5 mmHg (P < 0.01) without changing cerebral blood flow; cerebrovascular resistance decreased from 1.89 +/- 0.11 to 1.16 +/- 0.14 mmHg ml-1 min-1 (P < 0.01). During this hypotension, L-NAME increased arterial pressure to 87 +/- 6 mmHg (P < 0.05) and did not affect the hypotensive values for cerebral blood flow (P > 0.05); cerebrovascular resistance increased from the hypotensive values to 1.53 +/- 0.13 mmHg ml-1 min-1 (P < 0.05) (delta = 0.36 +/- 0.06 mmHg-1 ml-1 min-1), and this increment was lower than under control conditions (P < 0.01). Therefore, the role of nitric oxide in cerebrovascular response to hypotension may differ in each type of hypotension, as this role during hemorrhagic hypotension may not change and during hypotension by ganglionic blockade or diazoxide may decrease. These differences may be related to changes in nitric oxide release as stimuli on the endothelium (shear stress and sympathetic activity) may vary in each type of hypotension.

Adrenergic reactivity after inhibition of nitric oxide synthesis in the cerebral circulation of awake goats

The interaction between nitric oxide (NO) and adrenergic reactivity in the cerebral circulation was studied using in vivo and in vitro preparations. Blood flow to one brain hemisphere (cerebral blood flow) was electromagnetically measured in conscious goats, and the effects of norepinephrine, tyramine and cervical sympathetic nerve stimulation were recorded before (control) and after inhibition of NO formation with Nw-nitro-l-arginine methyl ester (l-NAME). The responses to norepinephrine, tyramine and electrical field stimulation were also recorded in segments, 4 mm in length, from the goat's middle cerebral artery under control conditions and after l-NAME. In vivo, l-NAME (10 goats, 47 mg kg-1 administered i.v.) reduced resting cerebral blood flow by 37+/-2%, increased mean systemic arterial pressure by 24+/-3%, reduced heart rate by 35+/-2%, and decreased cerebrovascular conductance by 52+/-2% (all P<0.01). Norepinephrine (0.3-9 microgram), tyramine (50-500 microgram), and supramaximal electrical sympathetic cervical nerve stimulation (1. 5-6 Hz) decreased cerebrovascular conductance, and these decreases were significantly higher after l-NAME than under control conditions, remaining higher for about 48 h after this treatment. Norepinephrine (10-8-10-3 M), tyramine (10-6-10-3 M) and electrical field stimulation (1.5-6 Hz) contracted isolated cerebral arteries, and the maximal contraction, but not the sensitivity, was significantly higher in the arteries treated than in non-treated with l-NAME (10-4 M). Therefore, the reactivity of cerebral vasculature to exogenous and endogenous norepinephrine may be increased after inhibition of NO synthesis. This increase might be related, at least in part, to changes at postjunctional level in the adrenergic innervation of the vessel wall, and it might contribute to the observed decreases in resting cerebral blood flow after inhibition of NO synthesis.

Cerebral reactive hyperaemia and arterial pressure in anaesthetized goats

The effects of arterial pressure on cerebral reactive hyperaemia were studied in anaesthetized goats measuring electromagnetically middle cerebral artery flow and performing arterial occlusions of 5-30 s. Under normotension (mean arterial pressure, MAP = 11 +/- 0.3 kPa), reactive hyperaemia (peak hyperaemic flow to control flow and repayment to debt ratios) increased, and cerebrovascular resistance during peak hyperaemic flow decreased, as ischaemia duration lengthened; the virtual maximal changes were obtained after 20 s ischaemia. During hypertension by aorta constriction (MAP = 18 +/- 0.7 kPa) or by i.v. infusion of noradrenaline (MAP = 19 +/- 0.8 kPa) middle cerebral artery flow did not change significantly and cerebrovascular resistance increased 25 and 46%, respectively (P < 0.05). During both types of hypertension reactive hyperaemia was over 50% higher, and the decrement in cerebrovascular resistance during peak hyperaemic flow was also higher, than under normotension. During hypotension by constriction of the inferior vena cava (MAP = 5 +/- 0.5 kPa) or by i.v. infusion of isoproterenol (MAP = 6 +/- 0.5 kPa), middle cerebral artery flow decreased 35% or did not change, and cerebrovascular resistance decreased 41 and 45%, respectively (P < 0.05). In these conditions, reactive hyperaemia and the decrement in cerebrovascular resistance during peak hyperaemic flow were reduced 80%, and it was similar in both types of hypotension. The absolute levels of cerebrovascular resistance obtained during peak hyperaemia were similar during normotension, hypertension and hypotension. Thus, arterial pressure is a main determinant of postocclusive cerebral reactive hyperaemia, and myogenic mechanisms may be of significance in determining the early stage of cerebral reactive hyperaemia after brief ischaemias. Adrenergic mechanisms might be of minor significance in this type of cerebral reactive hyperaemia.

The concept of coupling blood flow to brain function: revision required?

A tight coupling exists between brain function and cerebral perfusion in most situations. The Roy and Sherrington hypothesis has been widely accepted to account for the phenomenon: increased neuronal metabolic activity will give rise to the accumulation of vasoactive catabolites, which decrease vascular resistance and thereby increase blood flow until normal homeostasis is reestablished. However, the hypothesis does not account for the disproportionate increase in flow that occurs in a number of circumstances. There are additional difficulties in reconciling more recent experimental data with the Roy and Sherrington hypothesis. In this review we direct attention toward the rich perivascular nerve supply to all parts of the cerebral circulation as possibly being an alternative control system allowing for rapid parallel changes in flow and neuronal activity.

In vitro studies of the carotid rete mirabile of Artiodactyla

The carotid rete of Artiodactyla, an intracranial arterial plexus which supplies blood to the brain, has intrigued investigators for a long time. This study was designed to examine the responsiveness of isolated retial arteries (250-700 microns in external diameter) of goat, pig, and cattle. The findings in these arteries were compared to those observed in cerebral arteries (250-650 microns in external diameter) of the same animal species. The magnitude of the arterial responses to potassium chloride varied with the resting tension applied to the tissue. The two types of vessels exhibited similar resting tension values (0.3 g) for maximal tension development in response to potassium chloride; however, the ability of retial vessels to contract in the presence of potassium chloride was consistently smaller than that of cerebral arteries. The contractile response of retial arteries to norepinephrine (10(-9) to 10(-4) M), tyramine (10(-8) to 10(-3) M), and field electrical stimulation (2-16 Hz) was negligible. The same retial arteries exhibited dose-dependent contractions in response to 5-hydroxytryptamine (10(-9) to 10(-5) M) and histamine (10(-9) to 3 X 10(-4) M). Cerebral arteries exhibited larger responses to the vasoactive agents than retial arteries. Our findings indicate that retial arteries have a small vasomotor activity in response to adrenergic stimulation or to vasoactive agents. Therefore, the carotid rete of Artiodactyla may have a low ability to change resistance to blood flow under neural or hormonal influences.

GABA receptors mediate cerebral vasodilation in the unanesthetized goat

The effects of gamma-aminobutyric acid (GABA) and muscimol upon cerebral blood flow were evaluated in the unanesthetized goat. Cerebral blood flow was continuously measured by means of an electromagnetic flow probe chronically implanted on the internal maxillary artery after occlusion and thrombosis of the distal extracerebral vessels. Administration of GABA (1-100 micrograms) directly into the cerebral circulation produced dose-dependent increases in cerebral blood flow, without accompanying systemic effects. Muscimol mimicked the effects of GABA at doses 10 times lower. Administration of picrotoxin (1-3 mg) into the internal maxillary artery did not significantly change cerebral blood flow, but inhibited in a dose-dependent manner the vasodilation induced by GABA. Selective blockade of beta-adrenergic or muscarinic cholinergic receptors by propranolol or atropine, respectively, did not modify the cerebrovascular response to the GABAergic agonists. These results indicate that GABA increases total cerebral blood flow, acting on specific receptor sites in the cerebral blood vessels. The absence of influence of picrotoxin on resting cerebral blood flow suggests that the GABAergic receptors are not tonically activated under physiological conditions.

Nerve endings and pharmacological receptors in cerebral vessels

1. The cerebral vessels possess adrenergic, cholinergic, serotonergic and peptidergic innervations. 2. The cerebral vessels have alpha- and beta-adrenergic, cholinergic, serotonergic, histaminergic H1 and H2 and dopaminergic receptors whose activation by different agents causes vasomotor responses. 3. The induced effects by noradrenaline, adrenaline and serotonin are characterized by a cerebral vasoconstriction clearly manifested in man, the awake or anesthetized animal and isolated vessels. The vasoconstrictor response generally obeys an activation of specific receptors. 4. Under experimental conditions acetylcholine, histamine, dopamine and isoproterenol relax these vessels, in which cholinergic, H2-histaminergic, dopaminergic and beta-adrenergic (beta 1) receptors are implicated, respectively.

Relationship of cerebral blood flow to cardiac output, mean arterial pressure, blood volume, and alpha and beta blockade in cats

The relationship among cerebral blood flow (CBF), blood volume, cardiac output (CO), and mean arterial blood pressure (MABP) at varying levels of arterial CO2 tensions (PaCO2) were studied in 70 normal cats. The CBF was measured from the clearance curve of xenon-133 and CO with a thermal dilution catheter placed in the pulmonary artery. The CBF, CO, and MABP values varied appropriately with changes in PaCO2, confirming the reliability of the preparations and the presence of normal autoregulatory responses. Moderate hypovolemia that did not change MABP did, nevertheless, significantly decrease CO and CBF. In an effort to determine if this decrease in CO and CBF were coupled responses, the effects of beta stimulation, hypervolemia, and alpha and beta blockade were investigated. Propranolol, in a dosage insufficient to change MABP, decreased both CO and CBF. This agent abolished the CO response to elevations in PaCO2 but not the CBF response, making it unlikely that this CBF reduction resulted from impaired cerebral autoregulation. Isoproterenol, which, in contrast to propranolol, does not cross the normal blood-brain barrier, alone or in combination with phenoxybenzamine, produced a 38% and 72% increase in CO, respectively, without a change in CBF. Alpha blockade (no major change in CO) and beta blockage (major decrease in CO) did not significantly effect cerebral autoregulation to changes in MABP from angiotensin. The ability of the brain to resist increases in MABP and CO and maintain normal CBF is explained by normal cerebral autoregulation. However, its vulnerability to modest decreases in blood volume, which cannot be attributed to variations in perfusion pressure, is unexplained but obviously has important therapeutic implications. This may be related to reduction in CO, changes in autonomic activity, or a decrease in the size of the perfused capillary bed.

Sympathetic modulation of hypercapnic cerebral vasodilation in dogs

We measured cerebral blood flow using both the radioactive microsphere technique and the cerebral venous outflow technique in dogs anesthetized with chloralase. The effect of sympathetic stimulation on cerebral blood flow was observed during both normocapnia and prolonged hypercapnia using both blood flow techniques. The increase in blood flow with hypercapnia was the same with both methods. During hypercapnia the venous outflow method showed a 38% decrease and microspheres an 18% decrease in cerebral blood flow with sympathetic stimulation. At normal CO2, stimulation caused a decrease in cerebral venous flow: no change was observed with the microsphere method. Analysis of the blood flow patterns to extracerebral tissues and evaluation of extracerebral arterial reference samples failed to prove the existence of axial streaming and subsequent skimming of microspheres within the cephalic circulation. It is concluded that direct electrical stimulation of the sympathetic innervation of the cerebral vessels is capable of reducing cerebral blood flow even during a profound hypercapnic vasodilation.

Surgical treatment of vascular lesions of the spinal cord

Paravertebral block and resection of upper thoracic sympathetic ganglions were performed on cases in which vascular disturbance of the spinal cord was considered partly responsible. Block was performed in 14 cases and clinical improvement was seen in 10 cases out of them while resection was considered effective in 2 out of 3 cases. The evoked EMG of patients was assumed recovery of a part of synaptic function in the ischemic cord after the block. On the other hand, the skin temperature of the lower extremity did not show considerable change and this supports the view that the restoration of clinical picture was not due to the improvement of the periphral circulation of extremities. From these observations, it would be well presumed that favorable effect of sympathectomy consists partly in the improvement of vascular disturbance of the spinal cord.