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Bombardieri AM, Albers GW, Rodriguez S, Pileggi M, Steinberg GK, Heit JJ. Percutaneous cervical sympathetic block to treat cerebral vasospasm and delayed cerebral ischemia: a review of the evidence. J Neurointerv Surg 2023; 15:1212-1217. [PMID: 36597947 DOI: 10.1136/jnis-2022-019838] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/26/2022] [Indexed: 12/12/2022]
Abstract
Delayed cerebral ischemia (DCI) affects 30% of patients following aneurysmal subarachnoid hemorrhage (aSAH) and is a major driver of morbidity, mortality, and intensive care unit length of stay for these patients. DCI is strongly associated with cerebral arterial vasospasm, reduced cerebral blood flow and cerebral infarction. The current standard treatment with intravenous or intra-arterial calcium channel antagonist and balloon angioplasty or stent has limited efficacy. A simple treatment such as a cervical sympathetic block (CSB) may be an effective therapy but is not routinely performed to treat vasospasm/DCI. CSB consists of injecting local anesthetic at the level of the cervical sympathetic trunk, which temporarily blocks the innervation of the cerebral arteries to cause arterial vasodilatation. CSB is a local, minimally invasive, low cost and safe technique that can be performed at the bedside and may offer significant advantages as complementary treatment in combination with more conventional neurointerventional surgery interventions. We reviewed the literature that describes CSB for vasospasm/DCI prevention or treatment in humans after aSAH. The studies outlined in this review show promising results for a CSB as a treatment for vasospasm/DCI. Further research is required to standardize the technique, to explore how to integrate a CSB with conventional neurointerventional surgery treatments of vasospasm and DCI, and to study its long-term effect on neurological outcomes.
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Affiliation(s)
- Anna Maria Bombardieri
- Anesthesiology and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Gregory W Albers
- Neurology, Stanford University School of Medicine, Stanford, California, USA
| | - Samuel Rodriguez
- Anesthesiology and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Marco Pileggi
- Neuroradiology, Lugano Regional Hospital Civico and Italiano Sites, Lugano, Switzerland
| | | | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
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Bombardieri AM, Heifets BD, Treggiari M, Albers GW, Steinberg GK, Heit JJ. Cervical sympathectomy to treat cerebral vasospasm: a scoping review. Reg Anesth Pain Med 2023; 48:513-519. [PMID: 36424089 DOI: 10.1136/rapm-2022-103999] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/13/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND/IMPORTANCE Delayed cerebral ischemia (DCI) is the second-leading cause of death and disability in patients with aneurysmal subarachnoid hemorrhage (aSAH), and is associated with cerebral arterial vasospasm (CAV). Current treatments for CAV are expensive, invasive, and have limited efficacy. Cervical sympathetic block (CSB) is an underappreciated, but potentially highly effective therapy for CAV. OBJECTIVE To provide a comprehensive review of the preclinical and human literature pertinent to CSB in the context of CAV. EVIDENCE REVIEW This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. We conducted a literature search using Embase, PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus and Web of Science until February 2022, to identify abstracts, conference proceedings, and full-text papers pertinent to cervical sympathectomy and CAV in animal/adult patients. FINDINGS We included six human and six experimental studies. Human studies were mostly prospective observational, except one retrospective and one randomized clinical trial, and used various imaging modalities to measure changes in arterial diameter after the block. Studies that used digital subtraction angiography showed an improvement in cerebral perfusion without change in vessel diameter. Transcranial Doppler studies found an approximately 15% statistically significant decrease in velocities consistent with arterial vasodilatation. Overall, the results suggest an increase in cerebral arterial diameter and neurological improvement in patients receiving a CSB. Animal studies demonstrate that sympathetic system ablation vasodilates cerebral vasculature and decreases the incidence of symptomatic vasospasm. CONCLUSIONS This scoping review suggests that CSB may be a viable option for treatment and prevention of CAV/DCI in patients with aSAH, although the included studies were heterogeneous, mostly observational, and with a small sample size. Further research is needed to standardize the technique and prove its effectiveness to treat patients suffering of CAV/DCI after aSAH.
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Affiliation(s)
- Anna Maria Bombardieri
- Anesthesiology and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Boris D Heifets
- Anesthesiology and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Miriam Treggiari
- Anesthesiology and Perioperative Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gregory W Albers
- Neurology, Stanford University School of Medicine, Stanford, California, USA
| | - Gary K Steinberg
- Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Jeremy J Heit
- Radiology, Stanford University School of Medicine, Stanford, California, USA
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Salvagno M, Gouvea Bogossian E, Halenarova K, Ego A, Taccone FS. Cervical Ganglion Sympathectomy to Treat Cerebral Vasospasm in Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:241-249. [PMID: 36828982 DOI: 10.1007/s12028-023-01694-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/06/2023] [Indexed: 02/26/2023]
Abstract
Delayed cerebral ischemia (DCI) is still a significant cause of death and disability after aneurysmal subarachnoid hemorrhage. Cerebral vasospasm represents one of the most reported mechanisms associated with DCI. The management of DCI-related vasospasm remains a significant challenge for clinicians; induced hypertension, intraarterial vasodilators, and/or intracranial vessel angioplasty-particularly in refractory or recurrent cases-are the most used therapies. Because an essential role in the pathophysiology of cerebral vasospasm has been attributed to the adrenergic sympathetic nerves, a "sympatholytic" intervention, consisting of a temporary interruption of the sympathetic pathways using local anesthetics, has been advocated to minimize the vascular narrowing and reverse the consequences of cerebral vasospasm on tissue perfusion. In this review, we have analyzed the existing literature on the block of the cervical ganglions, particularly the stellate ganglion, in managing refractory cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. These findings could help clinicians to understand the potential role of such intervention and to develop future interventional trials in this setting.
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Affiliation(s)
- Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium.
| | | | - Katarina Halenarova
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Amedée Ego
- Department of Intensive Care, Hôpitaux Iris Sud, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium
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Cai Z, Cheng H, Xing Y, Chen F, Zhang Y, Cui C. Autonomic nervous activity analysis based on visibility graph complex networks and skin sympathetic nerve activity. Front Physiol 2022; 13:1001415. [PMID: 36160855 PMCID: PMC9500413 DOI: 10.3389/fphys.2022.1001415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 08/17/2022] [Indexed: 11/19/2022] Open
Abstract
Background: Autonomic nerve system (ANS) plays an important role in regulating cardiovascular function and cerebrovascular function. Traditional heart rate variation (HRV) and emerging skin sympathetic nerve activity (SKNA) analyses from ultra-short-time (UST) data cannot fully reveal neural activity, thereby quantitatively reflect ANS intensity. Methods: Electrocardiogram and SKNA from sixteen patients (seven cerebral hemorrhage (CH) patients and nine control group (CO) patients) were recorded using a portable device. Ten derived HRV (mean, standard deviation and root mean square difference of sinus RR intervals (NNmean, SDNN and RMSSD), ultra-low frequency (<0.003 Hz, uLF), very low frequency ([0.003 Hz, 0.04 Hz), vLF), low frequency ([0.04 Hz, 0.15 Hz), LF) and high frequency power ([0.15 Hz, 0.4 Hz), HF), ratio of LF to HF (LF/HF), the standard deviation of instantaneous beat-to-beat R-R interval variability (SD1), and approximate entropy (ApEn)) and ten visibility graph (VG) features (diameter (Dia), average node degree (aND), average shortest-path length (aSPL), clustering coefficient (CC), average closeness centrality (aCC), transitivity (Trans), average degree centrality (aDC), link density (LD), sMetric (sM) and graph energy (GE) of the constructed complex network) were compared on 5-min and UST segments to verify their validity and robustness in discriminating CH and CO under different data lengths. Besides, their potential for quantifying ANS-Load were also investigated. Results: The validation results of HRV and VG features in discriminating CH from CO showed that VG features were more clearly distinguishable between the two groups than HRV features. For effectiveness evaluation of analyzing ANS on UST segment, the NNmean, SDNN, RMSSD, LF, HF and LF/HF in HRV features and the CC, Trans, Dia and GE of VG features remained stable in both activated and inactivated segments across all data lengths. The capability of HRV and VG features in quantifying ANS-Load were evaluated and compared under different ANS-Load, the results showed that most HRV features (SDNN, LFHF, RMSSD, vLF, LF and HF) and almost all VG features were correlated to sympathetic nerve activity intensity. Conclusions: The proposed autonomic nervous activity analysis method based on VG and SKNA offers a new insight into ANS assessment in UST segments and ANS-Load quantification.
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Affiliation(s)
- Zhipeng Cai
- School of Instrument Science and Engineering, Southeast University, Nanjing, China
- *Correspondence: Zhipeng Cai, ; Chang Cui,
| | - Hongyi Cheng
- Department of Cardiology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Gusu School, Nanjing Medical University, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Yantao Xing
- School of Instrument Science and Engineering, Southeast University, Nanjing, China
| | - Feifei Chen
- School of Instrument Science and Engineering, Southeast University, Nanjing, China
| | - Yike Zhang
- Department of Cardiology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chang Cui
- Department of Cardiology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Zhipeng Cai, ; Chang Cui,
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Kim WJ, Dacey M, Samarage HM, Zarrin D, Goel K, Chan C, Qi X, Wang A, Shivkumar K, Ardell J, Colby G. Sympathetic nervous system hyperactivity results in potent cerebral hypoperfusion in swine. Auton Neurosci 2022; 241:102987. [DOI: 10.1016/j.autneu.2022.102987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/14/2022] [Accepted: 05/04/2022] [Indexed: 11/28/2022]
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Long J, He C, Dai H, Kang X, Zou J, Ye S, Yu Q. Effects of transection of cervical sympathetic trunk on cognitive function of traumatic brain injury rats. Neuropsychiatr Dis Treat 2019; 15:1121-1131. [PMID: 31118645 PMCID: PMC6506013 DOI: 10.2147/ndt.s199450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 03/28/2019] [Indexed: 01/04/2023] Open
Abstract
Objective: To observe the effects of transection of cervical sympathetic trunk (TCST) on the cognitive function of traumatic brain injury (TBI) rats and the potential mechanisms. Methods: A total of 288 adult male SD rats were divided into 3 groups using a random number table: TBI group (n=96), TBI + TCST group (n=96) and Sham group (n=96). The water maze test was performed before TBI (T0) and at day 1 (T1), day 2 (T2), day 3 (T3), 1 week (T4), 2 weeks (T5), 6 weeks (T6) and 12 weeks (T7) after TBI. The levels of α1-adrenergic receptors (α1-ARs), α2-adrenergic receptors (α2-ARs), toll-like receptor 4 (TLR-4) and P38 in hippocampi were detected by real-time PCR. Hippocampal P38 expression was assayed by Western blot. The expressions of interleukin-6 (IL-6), tumor necrosis factor (TNF-α) and brain-derived neurotrophic factor (BDNF) were examined by immunohistochemistry. Noradrenaline (NE) expression in plasma was evaluated by ELISA. The respiratory control ratio (RCR) of brain mitochondria was detected using a Clark oxygen electrode. Results: TCST effectively improved the cognitive function of TBI rats. TCST significantly inhibited sympathetic activity in the rats and effectively inhibited inflammatory responses. The expression of BDNF at T1-T6 in TBI+TCST group was higher than that in TBI group (P<0.05). Furthermore, P38 expression was inhibited more effectively in TBI+TCST group (P<0.05), than in TBI group (P<0.05), and the RCR of the brain was significantly higher in TBI+TCST group than in TBI group (P<0.05). Conclusions: TCST can enhance cognitive function in TBI rats by inhibiting sympathetic activity, reducing inflammatory responses and brain edema, upregulating BDNF and improving brain mitochondrial function.
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Affiliation(s)
- Juan Long
- Department of Pain, Guizhou Province People's Hospital, Guiyang, People's Republic of China
| | - Chunjing He
- Department of Pain, Guizhou Province People's Hospital, Guiyang, People's Republic of China
| | - Hong Dai
- Department of Neurology, Guizhou Province People's Hospital, Guiyang, People's Republic of China
| | - Xinguo Kang
- Department of Pain, Guizhou Province People's Hospital, Guiyang, People's Republic of China
| | - Jinfeng Zou
- Department of Pain, Guizhou Province People's Hospital, Guiyang, People's Republic of China
| | - Shengli Ye
- Department of Pain, Guizhou Province People's Hospital, Guiyang, People's Republic of China
| | - Qian Yu
- Department of Neurology, Guizhou Province People's Hospital, Guiyang, People's Republic of China
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Liu GD, He CJ. Stellate ganglion block promotes recovery of Bell's palsy in patients with diabetes mellitus. Acta Otolaryngol 2014; 134:652-5. [PMID: 24547956 DOI: 10.3109/00016489.2014.880794] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSION Stellate ganglion block (SGB) is effective for treatment of Bell's palsy in patients with diabetes mellitus. BACKGROUND Corticosteroids are widely used for treatment of Bell's palsy in patients with diabetes mellitus but may induce complications like hyperglycemia, which calls for an alternative therapy. This study aimed to ascertain the effect of SGB on Bell's palsy in patients with diabetes mellitus. METHODS This randomized and single-blinded clinical trial involved 96 diabetic patients with Bell's palsy that were randomly divided into a control group (n = 48) and a treatment group (SGB group, n = 48). The House-Brackmann scale and facial disability index (FDI, including FDIP and FDIS) were observed before treatment and at 1 and 3 months after treatment for assessment of the outcome. RESULTS No statistically significant difference was found between the two groups before treatment as regards the House-Brackmann scale and FDI. There was a statistically significant difference in FDIP score in the two groups after treatment in comparison with before treatment. The FDIS score showed a statistical difference between the two groups after treatment.
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Affiliation(s)
- Guo-Dong Liu
- Eighth Department, Research Institute of Surgery, Daping Hospital, Third Military Medical University , Chongqing
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