CEREBRAL THROMBOSIS AND EMBOLISM—A Method of Treatment

Acute cerebral thrombosis and embolism give rise to arterial spasm, edema, and anoxia of the cerebral tissues supplied by the affected artery or arteries. Sympathetic block induced by injecting the stellate ganglion with procaine appears to relieve spasm and results in improved cerebral circulation and clinical improvement in a significant number of cases. Sympathetic block should be combined with the usual supportive measures and not infrequently with anticoagulants. Every effort should be made to institute treatment as soon as possible after the onset of symptoms.     

LARYNGOSPASM FROM THE ANESTHESIOLOGIST'S VIEWPOINT

Laryngeal spasm is a problem constantly confronting the anesthetist. It can be serious and may produce fatal cerebral or cardiac complications. Etiologic agents include primary vagal hypertonicity, anoxemia, and painful stimulation of whatever source.Laryngeal spasm must be differentiated from simple obstruction by the tongue or foreign bodies, epiglottic impaction, laryngeal edema, tracheal spasm and collapse, and bronchial spasm.Proper checking of the patient before anesthesia and adequate premedication with atropine or scopolamine are preventive measures of great value. Once spasm has developed the etiologic agent should be removed if possible. Other measures include intravenous administration of atropine or curare, tracheal intubation, and tracheotomy.     

Intracarotid Phenoxybenzamine for Cerebral Arterial Spasm

Phenoxybenzamine was injected into the carotid artery of 23 patients after operations on their cerebral arterial aneurysms. Rapid improvement was seen in three cases with pronounced neurological disability. The other 20 were treated prophylactically in an attempt to prevent the onset of spasm. These results would appear to indicate that intracarotid phenoxybenzamine may be of value in the treatment of cerebral arterial spasm, provided that it is given before irreversible infarction of the brain has occurred. Until more is known about its action it would be best to give the drug only after operation.     

Intracranial Aneurysms

A reappraisal of case histories of patients with ruptured intracranial aneurysms emphasized the importance of clinically recognizing severe spasm that contraindicates early angiography and large cerebral haematomas that require immediate evacuation. Observation from the day of haemorrhage is important; most recurrent episodes with cerebral signs in the first 10 days were due to spasm; haemorrhage was more common during the following two weeks. In many attacks the signs were not sufficiently distinctive for diagnosis of spasm or haematoma.     

THE SELECTIVE ACTION OF NICOTINE ON THE CENTRAL NERVOUS SYSTEM OF THE SQUID,LOLIGO PEALII

1. In specimens of freshly hatched squid, Loligo pealii, nicotine acts upon the cerebral ganglia alone. 2. After 1 minute in the nicotine solution 1:500,000, the latent period for the mantle spasm is independent of the time spent in the solution. 3. The mantle spasm is conditioned by a chemical reaction, since the temperature coefficient of the process has a magnitude of about 2.8. 4. The velocity of the process which brings about the mantle spasm varies as the cube root of the concentration of the nicotine.     

Relaxant effects on iloprost in canine cerebral artery.

Iloprost caused relaxation of rings of canine cerebral arteries precontracted with prostaglandin F2 alpha or the thromboxane A2 analogue U46619, but it was without effect on arteries precontracted with potassium chloride. Pretreatment with iloprost did not significantly affect the concentration-response curve to any agent. Contractile responses to oxyhemoglobin were completed relaxed by iloprost. In arteries from animals with moderate cerebrovascular spasm, the response to prostaglandin F2 alpha was also reduced by iloprost. The observation that iloprost relaxes the response to oxyhemoglobin to prostaglandin F2 alpha in spastic arteries may be of interest in the management of cerebral vasospasm.     

Papaverine induces apoptosis in vascular endothelial and smooth muscle cells

Papaverine is a vasodilator commonly used in the treatment of vasospasmic diseases such as cerebral spasm associated with subarachnoid hemorrhage, and in the prevention of spasm of coronary artery bypass graft by intraluminal and/or extraluminal administration. In this study, we examined whether papaverine in the range of concentrations used clinically causes apoptosis of vascular endothelial and smooth muscle cells. Apoptotic cells were identified by morphological changes and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) assay. In porcine coronary endothelial cells (EC) and rat aortic smooth muscle cells (SMC), papaverine at the concentration of 10(-3) M induced membrane blebbing within 1 hour of incubation. Nuclear condensation and fragmentation were found after 24 hours of treatment. The number of apoptotic cells stained with the TUNEL method was significantly higher in the EC and the SMC after 24 hours of incubation with papaverine at the concentrations of 10(-4) and 10(-3) M than their respective controls. Acidified saline solution (pH 4.8, as control for 10(-3) M papaverine hydrochloride) did not cause apoptosis in these cells. These results showed that papaverine could damage endothelial and smooth muscle cells by inducing changes which are associated with events leading to apoptosis. Since integrity of endothelial cells is critical for normal vascular function, vascular administration of papaverine for clinical use, especially at high concentrations (> or = 10(-4) M), should be re-considered.     

表面肌电信号的下肢痉挛信号的特征分析与识别

脑卒中患者康复治疗中会引起下肢肌肉痉挛,这种现象给患者的康复训练过程带来极大的危害,因此能够在训练过程中识别痉挛并及时中断训练具有重要的实际意义。本研究通对下肢表面肌电信号的采集,采用基于形状的模版匹配法来识别痉挛信号,并以皮尔逊相关系数来分析表征下肢痉挛信号的相关性大小。分析结果表明,通过仿真验证了模版匹配法在个人痉挛信号识别中的准确性,显示了在泛用痉挛信号识别中的可行性。     

Muscle spasms associated with Sudeck's atrophy after injury.

Four patients developed abnormal involuntary movements of a limb after injury. All subsequently developed sympathetic algodystrophy with Sudeck''s atrophy and then abnormal muscle spasms or jerks of the affected limb, lasting years. Sympathetic block in three patients did not relieve the abnormal movements. Two patients obtained partial recovery spontaneously, but the other two required surgery for relief. The pathophysiology of this condition remains to be determined but the evidence suggests that it is a distinct, disabling clinical syndrome.     

Microsurgical Treatment of Hemifacial Spasm

Five cases of idiopathic hemifacial spasm have been successfully treated by operative manipulation of arterial branches compressing the VIIth nerve in the posterior fossa. Terminology, clinical presentation, pathology and therapeutic approaches to hemifacial spasm are discussed. Hearing loss due to operatively induced vascular impairment of the inner ear, a complication in our first case, should be avoidable.Our experience indicates that hemifacial spasm reflects mild chronic compression of the facial nerve. The proposed mechanism is transaxonal excitation between afferent and efferent fibers.     

Oxygen-conserving reflexes of the brain: the current molecular knowledge

The trigemino-cardiac reflex (TCR) may be classified as a sub-phenomenon in the group of the so-called 'oxygen-conserving reflexes'. Within seconds after the initiation of such a reflex, there is neither a powerful and differentiated activation of the sympathetic system with subsequent elevation in regional cerebral blood flow (CBF) with no changes in the cerebral metabolic rate of oxygen (CMRO₂) or in the cerebral metabolic rate of glucose (CMRglc). Such an increase in regional CBF without a change of CMRO₂ or CMRglc provides the brain with oxygen rapidly and efficiently and gives substantial evidence that the TCR is an oxygen-conserving reflex. This system, which mediates reflex protection projects via currently undefined pathways from the rostral ventrolateral medulla oblongata to the upper brainstem and/or thalamus which finally engage a small population of neurons in the cortex. This cortical centre appears to be dedicated to reflexively transduce a neuronal signal into cerebral vasodilatation and synchronization of electrocortical activity. Sympathetic excitation is mediated by cortical-spinal projection to spinal pre-ganglionic sympathetic neurons whereas bradycardia is mediated via projections to cardiovagal motor medullary neurons. The integrated reflex response serves to redistribute blood from viscera to brain in response to a challenge to cerebral metabolism, but seems also to initiate a preconditioning mechanism. Better and more detailed knowledge of the cascades, transmitters and molecules engaged in such endogenous (neuro) protection may provide new insights into novel therapeutic options for a range of disorders characterized by neuronal death and into cortical organization of the brain.     

Numerical analysis of hemodynamics in spastic middle cerebral arteries

Cerebral vasospasm (CVS) is the most common serious complication of subarachnoid hemorrhage. Among the many factors that are associated with the pathogenesis of CVS, hemodynamics plays an important role in the initiation and development of CVS. Numerical simulation was carried out to obtain the flow patterns and wall shear stress (WSS) distribution in spastic middle cerebral arteries. The blood was assumed to be incompressible, laminar, homogenous, Newtonian, and steady. Our simulations reveal that flow velocity and WSS level increase at the stenosis segment of the spastic vessels, but further downstream of stenosis, the WSS significantly decreases along the inner wall, and flow circulation and stagnation are observed. The hydrodynamic resistance increases with the increase of vessel spasm. Moreover, the change of flow field and hydrodynamic forces are not linearly proportional to the spasm level, and the rapid change of hemodynamic parameters is observed as the spasm is more than 50%. Accordingly, in the view of hemodynamic physiology, vessels with less than 30% stenosis are capable of self-restoration towards normal conditions. However, vessels with more than 50% stenosis may eventually lose their capacity to adapt to differing physiologic conditions due to the extreme non-physilogic hemodynamic environment, and the immediate expansion of the vessel lumen might be needed to minimize serious and non-reversible effects.     

The "no reflow" phenomenon in the cerebral cortex in the early postischemic period

Experiments on white rats with clinical death due to blood loss were made to demonstrate the presence of the "no-reflow" focuses in the cerebral cortex in the first minutes of recirculation. The microcirculatory disturbances were functional in nature and were determined by the spasm of the small intracranial arteries, arterioles and precapillary sphincters.     

Factors affecting massive postmortem bronchoconstriction in guinea pig lungs

To examine endogenous factors affecting the development of the massive bronchoconstriction in the postmortem guinea pig lung, 58 anesthetized open-chest animals were divided into three groups: 1) exsanguination only (n = 13), 2) pulmonary perfusion with 5% dextran and 1% bovine serum albumin (BSA) in Tyrode's solution (Ca2+ perfusate) (n = 21), and 3) pulmonary perfusion with 5% dextran and 1% BSA in saline (Ca2+-free perfusate) (n = 24). These groups were further divided into several subgroups according to treatments: 1) substance P depletion by chronic administration of capsaicin, 2) acute capsaicin treatment to release substance P, 3) dazoxiben treatment to block endogenous synthesis of thromboxane A2, 4) diethylcarbamazine treatment to eliminate leukotriene (LT) synthesis, and 5) FPL 55712 treatment to antagonize actions of LT. Vital capacity from the deflation pressure-volume (PV) curve of the lung was used as the indicator of bronchoconstriction. Most PV curves were performed for 30 min following exsanguination or artificial perfusion. Ca2+-free perfusate enhanced the airway spasm at 5-10 min, but the spasm disappeared gradually after 10 min. Substance P depletion significantly decreased (P less than 0.01) the bronchial constriction at 20-30 min, whereas substance P release induced severe airway spasm (P less than 0.01) during the entire study. In addition, FPL 55712 reduced the bronchospasm (P less than 0.05) in Ca2+ perfusate at 30 min. Thus Ca2+ and several endogenous mediators may be involved with the airway spasm of the postmortem guinea pig lung.     

Cerebral arteries can generate 5- and 15-hydroxyeicosatetraenoic acid from arachidonic acid

Products of the lipoxygenase pathway have been implicated in the development of the cerebrovascular spasm that arises after subarachnoid hemorrhage. In particular the hydroperoxyeicosatetranenoic acids (HPETEs), which are unstable and break down rapidly to the corresponding 5-hydroxy acids (HETEs), are vasoconstrictor agents that mimic some aspects of cerebrovascular spasm. It is not, however, well established whether segments of cerebral artery can manufacture these products. We have studied the lipoxygenase product profile of cerebral arteries stimulated with arachidonic acid. Rings of bovine cerebral arteries were incubated in Krebs solution containing arachidonic acid. The lipoxygenase products were studied using high performance liquid chromatography. The largest peaks had the retention times of 5- and 15-HETEs, and the identity of these peaks was confirmed using specific radioimmunoassays. Stimulation with arachidonic acid resulted in a time- and dose-dependent increase in the formation of both HETEs, with 15-HETE being most abundant. The release of both HETEs was markedly reduced in the presence of AA-861, an inhibitor of lipoxygenase, but not with the cyclooxygenase inhibitor indomethacin. These data are thus consistent with our previous suggestion that the contractile activity of arachidonic acid in cerebral arteries arises, at least in part, from HPETE formation and with a possible role for these compounds in cerebral vasospasm.     

Neural antagonists modulate pulmonary vascular pressure-flow plots in conscious dogs

Multipoint pulmonary vascular pressure-cardiac index (P/Q) plots were constructed in conscious dogs during normoxia by graded constriction of the thoracic inferior vena cava to reduce Q. P/Q plots were generated with the autonomic nervous system (ANS) intact and following total autonomic ganglionic block, cholinergic block, and sympathetic alpha- and beta-adrenergic block alone and in combination. With the ANS intact, the relationship between the pulmonary vascular pressure gradient [pulmonary arterial pressure (PAP)--pulmonary capillary wedge pressure (PCWP)] and Q was linear with an extrapolated pressure intercept of 0 mmHg. Total autonomic ganglionic block increased PAP-PCWP over the entire range of Q studied (60-140 ml . min-1 . kg-1). Cholinergic block resulted in a small increase in PAP-PCWP at a Q of 60 ml . min-1 . kg-1, a small decrease in PAP-PCWP at a Q of 140 ml . min-1 . kg-1, but no change in PAP-PCWP over the midrange of Q. Sympathetic beta-adrenergic block increased, and sympathetic alpha-adrenergic block decreased PAP-PCWP over the entire range of Q studied. Combined sympathetic alpha- and beta-adrenergic block also increased PAP-PCWP at each level of Q. Thus the ANS, either directly or via circulating catecholamines, exerts an active regulatory influence on the pulmonary vascular P/Q relationship of intact conscious dogs during normoxia over a wide range of Q. Activation of sympathetic beta-adrenergic receptors results in pulmonary vasodilatation, whereas, alpha-receptor activation results in vasoconstriction. Surprisingly, based on the effects of total autonomic ganglionic block and combined sympathetic alpha- and beta-adrenergic block, the net effect of the ANS on PAP-PCWP/Q during normoxia appears to be pulmonary vasodilatation.     

Protection of the blood-brain barrier during acute and chronic hypertension

A new concept about sympathetic nerves has emerged recently: not only is sympathetic tone important in short-term regulation of vascular resistance, but chronic effects of nerves on vessels have important effects. This concept is supported by studies of mechanisms by which sympathetic nerves protect the blood-brain barrier (BBB). The BBB is susceptible to disruption during acute and chronic hypertension. Acute, severe hypertension produces passive dilatation of cerebral vessels with disruption of the BBB. Sympathetic stimulation attenuates the increase in cerebral blood flow during acute hypertension and thereby protects the BBB. During chronic hypertension, we have observed disruption of the barrier, which may contribute to hypertensive encephalopathy. Sympathetic nerves protect against disruption of the BBB during chronic hypertension. This protective effect is apparently related to a trophic effect of nerves in promotion of cerebral vascular hypertrophy during chronic hypertension. Thus, this is the first evidence that, in the same vascular bed, sympathetic nerves have two different protective effects. Protection of the BBB is accomplished acutely by sympathetic neural effects on vascular resistance and chronically by promotion of vascular hypertrophy.     

Expression of the SM-20 Gene Promotes Death in Nerve Growth Factor-Dependent Sympathetic Neurons

Sympathetic neurons undergo apoptosis when deprived of nerve growth factor (NGF). Inhibitors of RNA or protein synthesis block this death, suggesting that gene expression is important for apoptosis in this system. We have identified SM-20 as a new gene that increases in expression in sympathetic neurons after NGF withdrawal. Expression of SM-20 also increases during neuronal death caused by cytosine arabinoside or the phosphatidylinositol 3-kinase inhibitor LY294002. In addition, SM-20 protein synthesis is elevated in NGF-deprived neurons compared with neurons maintained with NGF. Importantly, expression of SM-20 in sympathetic neurons causes cell death in the presence of NGF. These results suggest that SM-20 may function to regulate cell death in neurons.     

基于小波变换的婴儿痉挛症脑干听觉诱发电位复杂性分析

采用多尺度小波变换计算脑干听觉诱发电位近似熵的方法,对比婴儿痉挛症患儿与正常幼儿的近似熵值,按照脑干听觉诱发电位成份波对应的解剖位置,分段、分尺度计算并统计近似熵值,从神经信息传递角度探讨阻碍婴儿痉挛症患儿智能发育的原因。采集12例正常儿童和13例婴儿痉挛症患儿的脑干听觉诱发电位,将它们进行60尺度小波分解,分段、分尺度计算各尺度近似熵值。发现婴儿痉挛症组患儿脑干听觉诱发电位中代表脑干活动的3~7ms段的分尺度近似熵明显高于正常组(P<0.01),小尺度上表现尤为显著。结果表明婴儿痉挛症患儿脑干传导通路不畅通,其中的随机成份增多,阻碍信息在脑干的传递,进而影响患儿大脑皮层的发育。     

Hindlimb vascular responses to sympathetic augmentation during acute anemia

The effect of increased sympathetic activity on skeletal muscle blood flow during acute anemic hypoxia was studied in 16 anesthetized dogs. Sympathetic activity was altered by clamping the carotid arteries bilaterally below the carotid sinus. One group (n = 8) was beta blocked by administration of propranolol (1 mg/kg); a second group (n = 8) was untreated. Venous outflow from the left hindlimb was isolated for measurement of blood flow and O2 uptake (VO2). After a 20-min control period, both carotid arteries were clamped (CC) for 20 min followed by a 20-min recovery period. The sequence was repeated after hematocrit was lowered to about 15% by dextran exchange for blood. Prior to anemia, CC did not alter cardiac output or limb blood flow in either group. After induction of anemia, hindlimb resistance was higher with CC in the beta block than in the no block group. Both limb blood flow and VO2 fell in the beta-block group with CC during anemia. Beta block also prevented the additive increases in whole body VO2 seen with CC and induction of anemia. The data showed that the increased vasoconstrictor tone that was obtained with beta block during anemia was successful in redistributing the lower viscosity blood away from resting skeletal muscle, even to the point that muscle VO2 was decreased.