Local blood flow, oxygen tension, and oxygen consumption in the rat spinal cord. Part 1: Oxygen metabolism and neuronal function

Spinal cord constraints in the era of high-precision radiotherapy : Retrospective analysis of 62 spinal/paraspinal lesions with possible infringements of spinal cord constraints within a minimal volume

OBJECTIVE

Current constraints aim to minimize the risk of radiation myelitis by the use of restrictive maximal spinal cord doses, commonly 50 Gy. However, several studies suggested that a dose-volume effect could exist. Based on these observations, we evaluated patients receiving potentially excessive doses to the spinal cord within minimal volumes.

PATIENTS AND METHODS

Patients receiving radiotherapy between June 2010 and May 2015 using the Novalis^TM (Varian, Palo Alto, CA, USA; Brainlab, Heimstetten, Germany) radiosurgery system were retrospectively analyzed. A total of 56 patients with 62 treated lesions that had been prescribed radiation doses close to the spinal cord potentially higher than the common 50 Gy 2‑Gy equivalent-dose (EQD2) constraint were selected for further analysis. Of these patients, 26 with 31 lesions had no history of previous irradiation, while 30 patients with 31 lesions had been previously irradiated within the treatment field.

RESULTS

According to different dose evaluation approaches (spinal canal, spinal cord contour), 16 and 10 out of 31 primary irradiated lesions infringed constraints. For the 16 lesions violating spinal canal doses, the maximum doses ranged from 50.5 to 61.9 Gy EQD2. Reirradiated lesions had an average and median cumulative dose of 70.5 and 69 Gy, respectively. Dose drop-off was steep in both groups. Median overall survival was 17 months. No radiation myelitis or radiomorphological alterations were observed during follow-up.

CONCLUSION

This study adds to the increasing body of evidence indicating that excessive spinal cord doses within a minimal volume, especially in a reirradiation setting with topographically distinct high-point doses, may be given to patients after careful evaluation of treatment- and tumor-associated risks.

The oxygen paradox of neurovascular coupling

The coupling of cerebral blood flow (CBF) to neuronal activity is well preserved during evolution. Upon changes in the neuronal activity, an incompletely understood coupling mechanism regulates diameter changes of supplying blood vessels, which adjust CBF within seconds. The physiologic brain tissue oxygen content would sustain unimpeded brain function for only 1 second if continuous oxygen supply would suddenly stop. This suggests that the CBF response has evolved to balance oxygen supply and demand. Surprisingly, CBF increases surpass the accompanying increases of cerebral metabolic rate of oxygen (CMRO2). However, a disproportionate CBF increase may be required to increase the concentration gradient from capillary to tissue that drives oxygen delivery. However, the brain tissue oxygen content is not zero, and tissue pO2 decreases could serve to increase oxygen delivery without a CBF increase. Experimental evidence suggests that CMRO2 can increase with constant CBF within limits and decreases of baseline CBF were observed with constant CMRO2. This conflicting evidence may be viewed as an oxygen paradox of neurovascular coupling. As a possible solution for this paradox, we hypothesize that the CBF response has evolved to safeguard brain function in situations of moderate pathophysiological interference with oxygen supply.

Regional differences in radiosensitivity across the rat cervical spinal cord

PURPOSE

To study regional differences in radiosensitivity within the rat cervical spinal cord.

METHODS AND MATERIALS

Three types of inhomogeneous dose distributions were applied to compare the radiosensitivity of the lateral and central parts of the rat cervical spinal cord. The left lateral half of the spinal cord was irradiated with two grazing proton beams, each with a different penumbra (20-80% isodoses): lateral wide (penumbra = 1.1 mm) and lateral tight (penumbra = 0.8 mm). In the third experiment, the midline of the cord was irradiated with a narrow proton beam with a penumbra of 0.8 mm. The irradiated spinal cord length (C1-T2) was 20 mm in all experiments. The animals were irradiated with variable single doses of unmodulated protons (150 MeV) with the shoot-through method, whereby the plateau of the depth-dose profile is used rather than the Bragg peak. The endpoint for estimating isoeffective dose (ED(50)) values was paralysis of fore and/or hind limbs within 210 days after irradiation. Histology of the spinal cords was performed to assess the radiation-induced tissue damage.

RESULTS

High-precision proton irradiation of the lateral or the central part of the spinal cord resulted in a shift of dose-response curves to higher dose values compared with the homogeneously irradiated cervical cord to the same 20-mm length. The ED(50) values were 28.9 Gy and 33.4 Gy for the lateral wide and lateral tight irradiations, respectively, and as high as 71.9 Gy for the central beam experiment, compared with 20.4 Gy for the homogeneously irradiated 20-mm length of cervical cord. Histologic analysis of the spinal cords showed that the paralysis was due to white matter necrosis. The radiosensitivity was inhomogeneously distributed across the spinal cord, with a much more radioresistant central white matter (ED(50) = 71.9 Gy) compared with lateral white matter (ED(50) values = 28.9 Gy and 33.4 Gy). The gray matter did not show any noticeable lesions, such as necrosis or hemorrhage, up to 80 Gy. All lesions induced were restricted to white matter structures.

CONCLUSIONS

The observed large regional differences in radiosensitivity within the rat cervical spinal cord indicate that the lateral white matter is more radiosensitive than the central part of the white matter. The gray matter is highly resistant to radiation: no lesions observable by light microscopy were induced, even after a single dose as high as 80 Gy.

Epidemiology, demographics, and pathophysiology of acute spinal cord injury

Spinal cord injury occurs through various countries throughout the world with an annual incidence of 15 to 40 cases per million, with the causes of these injuries ranging from motor vehicle accidents and community violence to recreational activities and workplace-related injuries. Survival has improved along with a greater appreciation of patterns of presentation, survival, and complications. Despite much work having been done, the only treatment to date known to ameliorate neurologic dysfunction that occurs at or below the level of neurologic injury has been intravenous methylprednisolone therapy. Much research over the past 30 to 40 years has focused on elucidating the mechanisms of spinal cord injury, with the complex pathophysiologic processes slowly being unraveled. With a greater understanding of both primary and secondary mechanisms of injury, the roles of calcium, free radicals, sodium, excitatory amino acids, vascular mediators, and apoptosis have been elucidated. This review examines the epidemiology, demographics, and pathophysiology of acute spinal cord injury.

Evidence that nitric oxide- and opioid-containing interneurons innervate vessels in the dorsal horn of the spinal cord of rats

In the dorsal horn of the spinal cord, activation of small fibre nociceptive afferents leads to the release of nitric oxide and enkephalins by interneurons. In this work we encountered unexpected relationships among local spinal cord dorsal horn blood flow, specific forms of afferent input, nitric oxide and intrinsic opioids. Selective rises in rat lumbar dorsal cord blood flow using laser Doppler flowmetry and microelectrode hydrogen clearance polarography were generated by ipsilateral, 'nociceptive' low (3 Hz) frequency stimulation of sciatic afferents. Inhibitors of nitric oxide synthase (NOS) prevented rises in flow during stimulation without influencing baseline flow. Ipsilateral hindpaw intradermal injection of capsaicin, a nociceptive activator, also generated large rises in flow sensitive to NOS inhibition. During NOS blockade or morphine administration there were unexpected acute declines in the dorsal cord blood flow strictly confined to low frequency stimulation epochs. This acute vasoconstrictive effect was prevented by administration of an opioid receptor antagonist. Using immunohistochemistry, terminals apparently innervating dorsal spinal cord blood vessels were labelled with antibodies against neuronal NOS and met-enkephalin. We conclude that local nitric oxide and opioids, probably from interneurons, have competitive actions on dorsal horn microvessels once interneurons are activated during a nociceptive barrage. Collateral innervation of blood vessels may explain this property.

VEGF mRNA induction correlates with changes in the vascular architecture upon spinal cord damage in the rat

The multiple cellular and molecular processes induced by injury to the central nervous system (CNS) are still poorly understood. In the present study, we investigated the response of the vasculature and the expression of mRNA for the angiogenic vascular endothelial growth factor (VEGF) following X-irradiation of the spinal cord in the newborn and following traumatic spinal cord injury in the adult rat. Both lesion models induced changes in the density and the distribution pattern of blood vessels: while X-irradiation led to a permanent local increase in vascular density in the fibre tracts of the exposed segments, a transient local sprouting of vessels was induced upon traumatic spinal cord injury. In situ hybridization showed that an increase of VEGF mRNA anticipated and overlapped with the vascular responses in both lesion models. In addition to the temporal correlation of VEGF expression and vascular sprouting, there was a clear correlation in the spatial distribution patterns. Following X-irradiation, the expression of VEGF mRNA was restricted to the fibre tracts, precisely the areas where the changes in the vasculature were observed later on. Upon transection in the adult animal, VEGF was mainly detectable at the border of the lesion area, where the transient increase in vascular density could be observed. Interestingly, according to the type of lesion applied, astrocytes (X-irradiation) or inflammatory cells (presumably microglial cells or macrophages; traumatic lesion) are the cellular sources of VEGF mRNA. Our results strongly indicate that VEGF is crucially involved in mediating vascular changes following different types of injury in the CNS.

Mathematical modeling of time-dependent oxygen transport in rat peripheral nerve

We modeled time-dependent transport of oxygen in peripheral nerve. Simulation began with a steady-state oxygen tension field determined by capillary diameter and length, intercapillary distance, blood-flow velocity, oxygen consumption rate, and arterial oxygen tension. One of these parameters was assumed to change rapidly to new constant value, producing time-varying oxygen tensions. A monoexponential or biexponential function characterized the oxygen tension time variation. Rate constants of the slower exponential ranged from 0.017 sec-1 to 0.46 sec-1, implying minimal time lag in response of peripheral nerve oxygen tensions to alterations in blood flow, arterial blood oxygenation, or metabolic demands.

[Methods for measuring spinal cord blood flow]

This study aimed to review the techniques used most currently for measuring spinal cord blood blow flow (SCBF) in animals, i.e. the hydrogen clearance, labelled microspheres, 133Xe clearance and 14C-antipyrine autoradiographic methods. All four techniques may only be used in animals, because of their invasiveness. Flow figures varied greatly with the method, the spinal level at which measurements were carried out, and the species of animal. However, results tend to suggest that SCBF is very similar to cerebral blood flow in that it is controlled by chemical, autoregulatory and metabolic factors. Approaches to measuring SCBF in man may be made using stable xenon-enhanced computed tomographic imaging (Xes-CT) in the same way as for measuring cerebral blood flow. The calculation of SCBF is based on Fick's principle transformed by Kety and Schmidt. After a reference CT section has been obtained, twelve 8 mm thick sections are carried out whilst the patient breathes a 30% xenon-70% air/oxygen mixture. This series of views enables the SCBF to be calculated in four steps. Quantitative analysis in eight human subjects gave a mean SCBF of 58.8 +/- 5.96 ml x 100 g-1 x min-1. However, this method has a low signal to noise ratio. Moreover, the qualitative analysis of the parametric views of flow demonstrate tissue heterogeneity, partly due to the patient's movements (breathing movements). However, the method is non invasive, safe, and reproducible. As it can measure very low values of blood flow, the study of ischaemic spinal lesions is made possible, although some technical and software improvements are still required.

Protective effect of vitamin E on spinal cord injury by compression and concurrent lipid peroxidation

Studies were made on the influence of vitamin E on the effects of compression injury of the spinal cord associated with ischemia in rats. The motor disturbance induced by spinal cord injury was greatly reduced by vitamin E supplementation. After injury, the spinal cord evoked potentials showed greater recovery of both amplitude and latency in the vitamin E-supplemented group than in the control group. Spinal cord blood flow was promptly restored and remained normal after injury in the vitamin E-supplemented group, but was significantly decreased from 3 h after injury in the control group. Thiobarbituric acid (TBA)--reactive substances in the spinal cord was immediately increased by compression injury in both groups, and after injury it persisted at a high value for 24 h in the control group, but decreased within 1 h in the vitamin E-supplemented group. Pathological examination of the spinal cord showed less damage, such as bleeding and edema, in the vitamin E-supplemented group than in the control group. Vitamin E may have protective effects on the spinal cord by inhibiting damage induced by lipid peroxidation and/or by sustaining the blood flow by maintaining the normal metabolism of arachidonic acid.

Regulation of spinal cord blood flow in the rat as measured by quantitative autoradiography

Spinal cord blood flow (SCBF) and its response to alterations in blood gases and to systemic hypotension, haemodilution and barbiturate anaesthesia were measured in 47 rats at the level of Th 7-8 by quantitative autoradiography with [14C]iodoantipyrine ([14C]IAP) as tracer. During normocapnia and normoxia the mean SCBF values in the grey and white matter were 94 +/- 21 and 17 +/- 3 ml min-1 100 g-1, respectively. SCBF was highly dependent on PaCO2. Thus in hypercapnic animals (PaCO2 greater than 9 kPa) SCBF was increased in grey and white matter to 228 +/- 22 and 54 +/- 7 ml min-1 100 g-1, while during hypocapnia (PaCO2 less than 3.9 kPa) it was decreased to 64 +/- 14 and 11 +/- 2 ml min-1 100 g-1, respectively. Mean arterial blood pressure (MABP) was reduced by withdrawal of blood to 80 +/- 8 mmHg in a light hypotension group and to 53 +/- 11 mmHg in a severe hypotension group, compared with 126 +/- 13 mmHg in a control group. There was no significant difference in SCBF between the control group and the hypotension groups, suggesting that autoregulation is maintained down to an MABP of at least 50 mmHg. Normovolaemic haemodilution, with a reduction of the haematocrit from 50 +/- 2 to 33 +/- 3, increased SCBF to 113 +/- 9 ml min-1 100 g-1 in grey matter and to 21 +/- 12 ml min-1 100 g-1 in white matter.(ABSTRACT TRUNCATED AT 250 WORDS)

Local spinal cord glucose utilization in conscious and halothane-anaesthetized rats

The authors used the 2-[14C]deoxyglucose method to study local spinal and cerebral glucose utilization simultaneously during 1.2 per cent halothane anaesthesia in adult Sprague-Dawley rats. In conscious animals (n = 5) the rate of glucose utilization in lumbar spinal gray matter was about 50 per cent lower than that of cerebral cortex. Halothane anaesthesia (n = 6) reduced spinal cord and cerebral metabolic rate. Spinal glucose utilization was reduced 12-35 per cent, but this was less than the 45-70 per cent decrease halothane produced in 8 of 16 cerebral structures examined and was independent of the hypotension produced. These results indicate that halothane is a spinal metabolic depressant but that its effects on this tissue are substantially less than those it has on many cerebral structures.

A mathematical simulation of oxygen delivery in rat peripheral nerve

We have performed a mathematical simulation on a CYBER computer of the release, diffusion, and consumption of oxygen in the capillaries and surrounding tissue of peripheral nerve under steady-state conditions. The Krogh-Erlang equation was used to calculate oxygen tension in tissue, while numerical solution of the differential equation governing oxygen release from hemoglobin and diffusion was used to calculate oxygen tension in the capillary. Using average measured values for the parameters of oxygen solubility, diffusion coefficient, capillary diameter, capillary density, nerve blood flow, oxygen consumption rate, and arterial oxygen tension in rat peripheral nerve, we calculated the endoneurial oxygen tension as a function of distance from the nearest capillary and distance along the capillary from the arterial end to the venous end. The range of calculated values agreed with experimental measurements obtained from the sciatic nerves of rats. Alterations in these parameters produced changes in the calculated oxygen tension distributions. Conditions which adversely affected oxygen delivery include reduced capillary diameter, increased intercapillary distance, reduced blood flow, and reduced arterial oxygen tension. The lower experimentally obtained oxygen tensions in sciatic nerves of diabetic rats could be accounted for reasonably by this model on the basis of a 33% reduction in nerve blood flow (consistent with previously measured flow reduction). However, the measured reduction in oxygen tensions in sciatic nerves of rats with experimental galactose neuropathy were not as marked as those predicted on the basis of a 22% increase in tissue cylinder radius in the model (consistent with experimental observations). This may be due to the fact that the oxygen consumption rate is reduced in hypoxic regions of tissue.

The influence of hemorrhagic hypotension on spinal cord tissue oxygen tension

In order to investigate the spinal cord surface PO2 (sPO2) reaction to hypovolemic hypotension, nine female pigs (25 kg bw) were premedicated, anesthetized, intubated and artificially ventilated with N2O:O2 = 3:1. Following laminectomy from L3 to L5, sPO2 was measured on the dorsal side of the exposed spinal cord using six gold cathodes (luminal diameter 15 microns) while MAP (mean +/- SD) was lowered in steps of about 10 Torr by bleeding into a reservoir from 69.3 +/- 10.1 Torr to extreme low values of 13.3 +/- 3.1 Torr. Only a slight decrease of lumbar sPO2 (mean +/- SD) from 33.5 +/- 7.2 Torr to 27.6 +/- 4.8 Torr was evaluated from the data in response to MAP reduction to 50.2 +/- 3.5 Torr. Below that value, a marked proportional decrease of sPO2 and MAP was observed (0.65 Torr/Torr) corresponding to pressure passive flow behavior of the Hagen Poisseuille Law ("loss of autoregulation"). Four to five minutes after start of reinfusion both sPO2 and MAP showed an overshoot with maximum values of 54.0 +/- 11.1 Torr resp. 102.6 +/- 18 Torr. Initial values were approximated about 15 min. later. Histograms plotted from the individual sPO2 values of all pigs and of all the different experimental stages showed signs of severe hypoxia only if MAP was reduced below about 30 Torr. In general, this situation was reversible within reinfusion, only one of the nine pigs did not tolerate hemorrhagic hypoxia induced by MAP reduction to less than 30 Torr for at least 5-10 min. Nevertheless, the experiments showed a considerable circulatory stability in the investigated pigs.

Endoneurial oxygen tension and radial topography in nerve edema

Endoneurial edema occurs in numerous human and experimental neuropathies. We tested the hypothesis that the resultant increase in intercapillary distance (ICD) may result in endoneurial hypoxia. Experimental galactose neuropathy (EGN) was chosen since in this model, edema is due to the accumulation of galactitol, which does not directly damage nerve fibers, so that it was possible to study the role of endoneurial edema alone. We measured endoneurial oxygen tensions (PnO2) using oxygen-sensitive microelectrodes and related PnO2 radial topography to ICD. We also determined local oxygen consumption (VLO2) and critical PnO2(PcritO2). EGN and age-matched controls were studied at 4 months. (1) Caudal nerve conduction velocity was reduced in EGN. (2) The PnO2 values were reduced in EGN and the PnO2 histogram was shifted into the hypoxic range. These changes were paralleled by a significant increase in ICD in EGN. (3) The radial topography of PnO2 in EGN differed from the relatively uniform distribution in control nerves. In EGN the subperineurial PnO2 was significantly lower than the PnO2 at the center of the fascicle. These changes were paralleled by a significantly greater increase in ICD in the periphery. (4) That the PnO2 reduction in EGN was significant is suggested by the marked reduction in VLO2 and the large percentage (greater than 75%) of intrafascicular regions that fell below PcritO2 in EGN.

Increase in rat spinal cord blood flow with the calcium channel blocker, nimodipine

Nimodipine, a calcium channel blocker, is known to increase cerebral blood flow. In the present study, the authors investigated the effect of nimodipine on spinal cord blood flow in normal rats. Cardiovascular parameters, including mean systemic arterial blood pressure, cardiac output, and heart rate, were recorded during infusion of nimodipine in a dose-response fashion. The experiment was a randomized blind study in which four groups of five rats received different doses of nimodipine (0.001, 0.01, 0.05, and 0.10 mg/kg) intravenously over 30 minutes, and a control group of five rats received only the diluent. The hydrogen clearance and thermodilution techniques were used to measure spinal cord blood flow and cardiac output, respectively. The 0.05-mg/kg dose of nimodipine caused the largest increase in spinal cord blood flow, with a 40% increase over the preinfusion level, although there was a 25% reduction in mean arterial pressure. The 0.10-mg/kg dose did not increase spinal cord blood flow more than the 0.05-mg/kg dose, most likely due to the concomitant 37% reduction in mean arterial pressure. Cardiac output was significantly increased by the 0.05- and 0.10-mg/kg doses secondary to the drop in total peripheral resistance. The increase in spinal cord blood flow produced by nimodipine lasted approximately 20 minutes after the termination of the infusion. Thus, nimodipine at a dose of 0.05 mg/kg markedly increased blood flow in the normal spinal cord even though there were major changes in mean systemic arterial pressure and cardiac output. Further research is required to determine whether this drug might be beneficial in treating ischemic states of the spinal cord, such as posttraumatic ischemia.

Effects of a single large dose of methylprednisolone sodium succinate on experimental posttraumatic spinal cord ischemia. Dose-response and time-action analysis

The ability of a single large intravenous dose of methylprednisolone sodium succinate (MPSS: 15, 30, or 60 mg/kg) to modify the evolution of lumbar spinal cord ischemia in cats undergoing a contusion injury of 500 gm-cm is examined. Repeated measurements of spinal cord blood flow (SCBF) in the dorsolateral funiculus were made via the hydrogen clearance technique before and for 4 to 5 hours after injury. The mean preinjury SCBF for all animals was 12.29 +/- 0.77 ml/100 gm/min. Following injury, SCBF began to decrease progressively in vehicle-treated animals to a level of 7.71 ml/100 gm/min, a fall of 37.3%. In contrast, cats that received a 30-mg/kg intravenous dose of MPSS at 30 minutes after injury maintained SCBF within normal limits (p less than 0.05 at 3 and 4 hours after contusion). A 15-mg/kg MPSS dose was less effective at preventing posttraumatic white matter ischemia, and a 60-mg/kg dose was essentially ineffective. It was determined that the 30-mg/kg MPSS dose was optimal for supporting SCBF when the drug was given at 30 minutes after spinal trauma, and a second series of experiments was carried out to examine the ability of this dose, when given at longer latencies, to improve decreased flow. Methylprednisolone given at 1 1/2 hours after injury in four cats produced a slight (12.7%) but transient improvement in SCBF, and when administered at 4 1/2 hours in another three animals was totally ineffective. These results show that MPSS in a 30-mg/kg dose can prevent posttraumatic spinal cord ischemia. However, it would appear that the ability of the steroid to reverse the ischemia once it has developed is limited, and probably lost, within a few hours of onset. This further suggests that the ischemic process is irreversible and underscores the need for early treatment with a large MPSS dose in order to prevent full development of ischemia and to promote neurological recovery.

Response of spinal cord oxygen tension to aortic occlusion

In order to study the factors influencing spinal cord injury resulting from occlusion of the descending aorta, the local surface PO2 (sPO2) was measured in the lumbar region (L4-5) of the exposed spinal cord after laminectomy in the pig. This is the area supplied by the arteria radicularis magna anterior (ARMA). The following aspects were considered: duration of occlusion, blood supply by the ARMA, distribution and width of spinal cord collaterals. The animals were divided into two groups. In group I (n = 7) the descending aorta was occluded immediately below the left subclavian artery; in group II (n = 7) the abdominal aorta was occluded immediately superior to the ARMA. Occlusion induced a rapid sPO2 decrease in all animals, from 29 to 3 mm Hg in group I (-14 mm Hg/min) and from 28 to 8 mm Hg in group II (-12 mm Hg/min). After 45 minutes of occlusion the blood flow through the aorta was released giving a pronounced sPO2 overshoot (36 mm Hg) about 10 minutes later. After 20 minutes there had been a return to initial sPO2 values. The results of this study confirm the hypothesis that spinal cord injury during occlusion of the descending aorta is primarily due to ischemic hypoxia/anoxia.

Local blood flow, oxygen tension, and oxygen consumption in the rat spinal cord. Part 2: Relation to segmental level

Using a reliable and reproducible microelectrode technique, consistent simultaneous measurements of local spinal cord blood flow (SCBF), tissue oxygen tension, and tissue oxygen consumption were made at cervical, thoracic, and lumbar levels in the rat spinal cord. These observations showed that the metabolic state is maintained constant along the cord, despite significant variations in vasculature. The physiological and anatomical aspects of these findings are discussed.

Simultaneous measurement of local blood flow and tissue oxygen in rat spinal cord

Measurement of local blood flow by hydrogen clearance is a useful technique and is compatible with simultaneous measurement of oxygen tension over long periods. However, existing methods present serious limitations of spatial resolution due to high diffusion rates and other factors. Improved methods permit local measurements in both gray and white matter of the rat spinal cord that correlate well with data from autoradiographic techniques, and indeed distinguish between individual gray matter laminae. Applications of similar methods should be useful in other systems where high spatial resolution is required.