Arterial pressure and plasma vasopressin: regulation by neurons in the caudal ventrolateral medulla of the rabbit

Hypertension of neurogenic origin: effect of microvascular decompression of the CN IX-X root entry/exit zone and ventrolateral medulla on blood pressure in a prospective series of 48 patients with hemifacial spasm associated with essential hypertension

OBJECT

In spite of solid anatomical and physiological arguments and the promising results of Jannetta in the 1970s, treating essential hypertension by microvascular decompression (MVD) of the brainstem has not gained acceptance as a mainstream technique. The main reason has been a lack of established selection criteria. Because of this, the authors' attempts have been limited to patients referred for MVD for hemifacial spasm (HFS) who also had hypertension likely to be related to neurovascular compression (NVC).

METHODS

Of 201 patients referred for HFS, 48 (23.8%) had associated hypertension. All had high-resolution MR images that demonstrated NVC. All underwent MVD of the root exit/entry zone (REZ) of the ninth and tenth cranial nerves (CN IX-X) and adjacent ventrolateral medulla in addition to the CN VII REZ. Effects on hypertension, graded using the WHO classification, were studied up to the latest follow-up, which was 2–16 years from the time of surgery, 7 years on average. Also, effects of MVD on blood pressure (BP) according to the side of vascular compression were evaluated.

RESULTS

Preoperatively, hypertension was severe in all but 1 of the patients; in spite of medical treatment, 47 patients still had WHO Grade 1 or 2 hypertension, and 18 still had unstable BP. After MVD, at latest follow-up, BP had returned to normal (i.e., systolic pressure < 140 mm Hg) in 28 patients; 14 of these patients (29.10% of the whole series) were able to maintain normal BP without any antihypertensive treatment; the other 14 still required some medication to maintain their BP below 140 mm Hg (p < 0.0001). Also, at latest follow-up, BP remained unstable in only 8 of the 18 patients with instability prior to MVD (p < 0.02). Analysis according to side of compression showed that of the 30 patients with left-sided compression, 17 had their BP normalized (without medication in 11 cases), and of the 18 patients with right-sided compression, 11 had their BP normalized (without medication in 3 cases). The difference between sides was not significant.

CONCLUSIONS

These results argue for considering MVD for the treatment of hypertension likely to be due to NVC at the CN IX-X REZ and adjacent ventrolateral medulla. Criteria for selecting patients with hypertension alone still need to be established and could include the following indications: apparently essential hypertension, likely to be neurogenic, in patients in whom high-resolution MRI shows clear-cut images of NVC at the CN IX-X REZ and adjacent ventrolateral medulla and in whom BP cannot be controlled by medical treatment.

Is there a place for microsurgical vascular decompression of the brainstem for apparent essential blood hypertension? a review

There are anatomical and physiological evidences that the ventrolateral (VL) region of the medulla plays an important role in blood pressure regulation and that dysfunction at this level may generate hypertension (HT). Vascular compression by a megadolicho-artery from the vertebrobasilar arterial system at the root entry/exit zone (REZ) of the glossopharyngeal (IXth) and vagal (Xth) cranial nerves (CNs) and the adjacent VL aspect of the medulla has been postulated as a causal factor for HT from neurogenic origin. The first attempts at microvascular decompression (MVD) of the IX-Xth CNs together with the neighbouring VL brainstem was revealed promising. These surgical attempts, as well as the numerous MRI studies, with the goal to detect and identify likely responsible neurovascular conflicts (NVC), are reviewed. Established criteria for indication of MVD as an aetiological treatment of apparent essential HT are still needed.

Beta-endorphin-, adrenocorticotrophic hormone- and neuropeptide y-containing projection fibers from the arcuate hypothalamic nucleus make synaptic contacts on to nucleus preopticus medianus neurons projecting to the paraventricular hypothalamic nucleus in the rat

The nucleus preopticus medianus is known to be situated in a key site in pathways regulating the paraventricular hypothalamic nucleus. To investigate the innervation pattern to nucleus preopticus medianus neurons by afferent fibers containing beta-endorphin, adrenocorticotrophic hormone and neuropeptide Y, a retrograde tracing method was combined with immunohistochemistry for these peptides in the rat. In the first experiment with injection of a retrograde tracer in the nucleus preopticus medianus, retrogradely labeled neurons were found in many regions throughout the brain. Among these, the arcuate hypothalamic nucleus contained a number of retrogradely labeled neurons showing immunoreactivity to the neuropeptides examined. About 20%, 20% and 40% of retrogradely labeled arcuate hypothalamic nucleus neurons showed beta-endorphin, adrenocorticotrophic hormone and neuropeptide Y immunoreactivity, respectively. About 18% and 57% of retrogradely labeled neurons in the nucleus tractus solitarius and ventrolateral medulla, respectively, were immunoreactive to neuropeptide Y. There were many more neuropeptide Y-immunoreactive projections to the nucleus preopticus medianus from the arcuate hypothalamic nucleus than those from the medulla. None of the retrogradely labeled neurons in the medulla showed immunoreactivity to beta-endorphin or adrenocorticotrophic hormone. In the second experiment with injection of a retrograde tracer in the paraventricular hypothalamic nucleus, electron microscopic observation revealed that retrogradely labeled neurons in the nucleus preopticus medianus were in synaptic contact with beta-endorphin-, adrenocorticotrophic hormone- and neuropeptide Y-immunoreactive axon terminals. The present finding indicates that nucleus preopticus medianus neurons projecting to the paraventricular hypothalamic nucleus are innervated by beta-endorphin-, adrenocorticotrophic hormone- and neuropeptide Y-containing arcuate hypothalamic nucleus neurons in addition to being innervated by neuropeptide Y-containing catecholaminergic medullary neurons which have been reported in our previous study.

Role of the solitary tract nucleus and caudal ventrolateral medulla in temperature responses in endotoxemic rats

In experiments on conscious rats it was found that preliminary microinjection of 100 nl 100 microM glutamic acid to the rostral commissural part of the solitary tract nucleus or to the caudal ventrolateral medulla increased a rise in colonic temperature induced by systemically applied endotoxin (3 microg/kg Escherichia coli lipopolysaccharide, i.p.) as compared to animals with intrabulbar injection of vehicle (control group). Preliminary microinjection of glutamate to the caudal commissural part of the solitary tract nucleus levelled the endotoxin-induced temperature response. After glutamate treatment of the caudal ventrolateral medulla there was a significant decrease in the noradrenaline content and decrease in the adrenaline level in the caudal (not significant) and rostral ventrolateral medulla (significant), as well as a small rise in noradrenergic activity at the solitary tract nucleus as compared to control animals. The post-mortem measurement of the optical density of brainstem tissues revealed its significant attenuation at the solitary tract nucleus and caudal ventrolateral medulla after glutamate as compared with these structures after vehicle. The involvement of monoaminergic systems of both structures under study in the initiation and control of temperature responses during endotoxemia is suggested.

Are the capsaicin-sensitive structures of ventral medulla involved in the temperature response to endotoxin in rats?

In chronic experiments on rats pretreated with bilateral microinjection of 25 nl 1% capsaicin to the caudal ventrolateral medulla under ketamine-xylazine-acepromazine anesthesia, an enhancement of the temperature response to intraperitoneal application of 3 microg/kg E. coli lipopolysaccharide as compared to animals who received vehicle to the caudal ventrolateral medulla was found. This is indicative of the involvement of the capsaicin-sensitive bulbar structures in thermoregulatory processes during endotoxemia.

The C1 area of rostral ventrolateral medulla: a central site integrating autonomic responses to hemorrhage

Activation of the sympathetic neurons and release of adrenomedullary catecholamines are the principal early reflex responses to hemorrhage. These are initiated by arterial baro- and chemoreceptors, from other cardiopulmonary receptors, and by intracerebral receptors responding to ischemia. A principal gateway for integrating the autonomic responses are a small collection of neurons in a region of the rostral ventrolateral medulla (RVL), containing a cluster of neurons of the C1 adrenergic cell group, the C1 area. Neurons in the C1 area of RVL project exclusively to autonomic nuclei of the spinal cord, are tonically active, and fire with a rhythm linked to the cardiac cycle. They are essential for maintaining resting discharge of sympathetic nerves and, consequently, arterial pressure (AP) and heart rate. They also are critical for reflex changes in AP in the baro- and chemoreceptor, somato-sympathetic (pain), and cerebral ischemic reflexes. Neurons of the C1 area are under tonic excitatory and inhibitory control by pathways from other autonomic centers. They are controlled by a range of neurotransmitters including, gamma aminobutyric acid (GABA), acetylcholine, catecholamines, enkephalin, and several neuropeptides. They also serve as a site of action for the hypotensive actions of several clinically important neurotransmitters. The C1-area of RVL may play a critical role in the autonomic responses to hemorrhage and may be an important target for drugs seeking to treat hemorrhagic shock.

Collateral axonal projections from the A1 noradrenergic cell group to the paraventricular nucleus and bed nucleus of the stria terminalis in the rat

The A1 noradrenergic cell group in the caudal ventrolateral medullary reticular formation of the rat sends efferent projections to a number of regions in the basal forebrain and hypothalamus, but the extent to which these projections represent collateral branches of individual axons is not known. Immunohistochemical labeling of medullary neurons containing the catecholamine biosynthetic enzymes tyrosine hydroxylase, dopamine beta-hydroxylase, and phenylethanolamine N-methyltransferase was used to reveal the anatomical location of A1 noradrenergic neurons within the ventrolateral medulla. Subsequently, the retrograde fluorescence double-labeling technique was employed to investigate the collateralization of ascending A1 efferent axons. The subcommissural bed nucleus of the stria terminalis (BST) was injected with rhodamine-fluorescent latex microspheres and the ipsilateral left paraventricular nucleus of the hypothalamus (PVN) was injected with Fast blue. Within the ventrolateral medulla, single- and double-labeled neurons were identified in a distribution corresponding to that demonstrated for A1 noradrenergic perikarya. The results indicate that some ascending axons from cells within the A1 region collateralize to effect a simultaneous innervation of the BST and PVN. The innervation of multiple efferent targets by single neurons within the A1 region may have important implications with respect to A1's postulated role in central cardiovascular regulation.