Effect of flunarizine on canine cerebral cortical blood flow and vascular resistance post cardiac arrest

Analytic Reviews : Potential New Therapies for Acute Ischemic Stroke

Evidence from animal models of acute stroke suggests ischemia may be reversible if blood flow is restored in the first few hours. Studies of human stroke using posi tron emission tomography demonstrate areas with re duced blood flow and relatively preserved metabolism, indicating potentially reversible ischemic brain. Resto ration of blood flow during this reversible phase should improve outcome after stroke.

Many therapeutic strategies for treatment of acute ischemic stroke have been proposed, including increas ing collateral flow, removing vascular obstructions, and interfering with the intracellular cascade of events that lead to neuronal cell death. Hypervolemic hemodilution reduces viscosity and increases cerebral blood flow, and this may hopefully raise blood flow above the critical threshold of irreversible ischemia. Naloxone, calcium channel blockers, and glutamate antagonists alter blood flow and influence intracellular events during and after acute ischemia. Thrombolytic therapy restores blood flow by lysis of obstructing clot. These therapies show promise in preliminary studies, but additional ran domized controlled studies are needed.

Ischemia-mediated neuronal injury

Resuscitation of the brain after a period of global ischemia is limited by two classes of post-ischemic pathologies: hemodynamic disturbances which prevent the adequate re-oxygenation of the ischemic brain, and metabolic disturbances which may lead to delayed neuronal death in so-called selectively vulnerable brain regions. The hemodynamic disturbances can be classified into the no-reflow phenomenon and the post-ischemic hypoperfusion syndrome. The no-reflow phenomenon results from a combination of increased blood viscosity and perivascular edema; the severity increases with the duration of ischemia, and the treatment is by combining arterial hypertension with dehydration and anticoagulation. The post-ischemic hypoperfusion syndrome is independent of the duration of ischemia, it develops after a delay and is due to an impairment of the metabolic/hemodynamic coupling mechanisms; there is no specific treatment at the present. The most important metabolic disturbance leading to delayed neuronal death is prolonged inhibition of protein synthesis. The injury is manifested already after 5 min ischemia but it progresses little if ischemia is prolonged to 1 h. Inhibition occurs at the translation level due to selective inhibition of polypeptide chain initiation. After brief periods of ischemia, the disturbance can be reversed by various anesthetics and hypothermia but there is no treatment if ischemia is prolonged. Exitotoxity, free radical-mediated reactions, disturbances of polyamine metabolism, acidosis and selective disturbances of gene expression may also be involved but are probably of lesser importance.

Chronological atrophy after transient middle cerebral artery occlusion in rats

We studied the development of brain atrophy after transient focal ischemia in rats. The animals were subjected to cerebral ischemia induced by embolization of the right middle cerebral artery (MCA) for 60 min. The brains were studied morphologically 7 days, 1 month, 3 months and 9 months after recirculation. In addition, the effects of a new calcium antagonist, KB-2796, and a glutamate receptor antagonist, 6,7-dinitroquinoxaline-2,3-dione (DNQX); were evaluated in this model 1 month after ischemia. The hemispheric volume of the ipsilateral ischemic side, expressed as a percentage of that on the contralateral non-ischemic side, was 99% in the sham operation group, 94% at 7 days, 87% at 1 month, 68% at 3 months and 65% at 9 months. Atrophy of the striatum and cortex, but not the hippocampus, was observed 1 month after ischemia. Atrophy of the ipsilateral substantia nigra and the thalamus, which are remote from the ischemic region, was observed 7 days and 1 month, respectively, after ischemia. Correlations between the extent of the atrophy in the striatum and that in the substantia nigra and between the extent of the atrophy in the cortex and in the thalamus were statistically significant. Treatment with KB-2796 or DNQX administered intraperitoneally at a dose of 10 mg/kg twice 30 min before ischemia and immediately after ischemia was effective in reducing the extent of atrophy in both the ipsilateral ischemic and non-ischemic regions. These results suggest that brain atrophy on the ipsilateral ischemic side develops time-sequentially after transient focal ischemia and that ischemia affects not only the primary ischemic focus but also remote regions through transsynaptic connections, and that KB-2796 and DNQX have beneficial effects on atrophy in the chronic phase after ischemia.

Cerebral resuscitation after cardiac arrest: research initiatives and future directions

At present, fewer than 10% of cardiopulmonary resuscitation (CPR) attempts prehospital or in hospitals outside special care units result in survival without brain damage. Minimizing response times and optimizing CPR performance would improve results. A breakthrough, however, can be expected to occur only when cerebral resuscitation research has achieved consistent conscious survival after normothermic cardiac arrest (no flow) times of not only five minutes but up to ten minutes. Most cerebral neurons and cardiac myocytes tolerate normothermic ischemic anoxia of up to 20 minutes. Particularly vulnerable neurons die, in part, because of the complex secondary post-reflow derangements in vital organs (the postresuscitation syndrome) which can be mitigated. Brain-orientation of CPR led to the cardiopulmonary-cerebral resuscitation (CPCR) system of basic, advanced, and prolonged life support. In large animal models with cardiac arrest of 10 to 15 minutes, external CPR, life support of at least three days, and outcome evaluation, the numbers of conscious survivors (although not with normal brain histology) have been increased with more effective reperfusion by open-chest CPR or emergency cardiopulmonary bypass, an early hypertensive bout, early post-arrest calcium entry blocker therapy, or mild cerebral hypothermia (34 C) immediately following cardiac arrest. More than ten drug treatments evaluated have not reproducibly mitigated brain damage in such animal models. Controlled clinical trials of novel CPCR treatments reveal feasibility and side effects but, in the absence of a breakthrough effect, may not discriminate between a treatment's ability to mitigate brain damage in selected cases and the absence of any treatment effect. More intensified, coordinated, multicenter cerebral resuscitation research is justified.

The effects of nicardipine given after 10-minutes complete global cerebral ischemia on neurologic recovery in dogs

The effect of nicardipine (NC) on neurologic recovery from ischemic insult after 10-minutes complete global cerebral ischemia was evaluated in dogs by examination of neurologic recovery score (NRS: complete recovery = 100, death = 0). Ischemia was achieved by occlusion of ascending aorta, and NC, 10 microg.kg(-1) in bolus followed by infusion of 0.33 microg.kg(-1).min(-1) for 2 hours, was administered immediately after re-establishment of circulation. The mortality at 7th day was 2/9 in the control Copyright and 1/9 in the NC group (ns). NRS on 2nd day was 52.3 +/- 6.8 in the C and 70.6 +/- 6.5 in the NC ( P < 0.05), but that on 7th day did not differ between the two groups. The numbers of dogs recovered to over 80 in NRS on the 2nd day was 1/9 in the C and 5/9 in the NC ( P < 0.05), but that on the 7th day increased to 3/9 in the C and remained at 5/9 in the NC (ns). These results suggest that NC accelerates the early neurologic recovery from ischemic damage, but influences little the final outcome.

The use of a calcium-channel blocker, nicardipine, for severely asphyxiated newborn infants

A continuous infusion of nicardipine was given to four severely asphyxiated fullterm infants who were at high risk for adverse outcome and had abnormal cerebral Doppler haemodynamic studies. The heart rate increased in all four infants and mean arterial blood pressure (MAP) fell in three. Two infants had a sudden and marked fall in MAP, together with severe impairment of skin blood-flow and a concurrent fall in cerebral blood-flow velocity. The serum level of nicardipine was less than 40ng/mL in all cases. The use of nicardipine, and possibly other calcium-channel blockers, may be associated with marked hypotension, and if there is no cerebral autoregulation, may cause further cerebral hypoperfusion, so use of these drugs in asphyxiated newborn infants should only be attempted if blood pressure is carefully monitored.

Effect of nimodipine on ischemia-induced brain edema and mortality in a novel transient middle cerebral artery occlusion model

A novel transient middle cerebral artery (MCA) occlusion model in the rat was used to evaluate the effect of nimodipine on brain edema and mortality. Nimodipine (30 micrograms/kg) administered immediately after 3 hr of transient unilateral MCA occlusion attenuated significantly the post-ischemic increase of tissue water content and partly attenuated 45Ca accumulation in the parieto-temporal cortex ipsilateral to the left MCA occlusion 3 hr after reperfusion. Nimodipine decreased the mortality rate at 6 and 9 hr after recirculation, although the survival rate at 24 hr after recirculation was not different from the control group. These results suggest that nimodipine has beneficial effects in the early phase of the reperfusion period.

Brain hypoperfusion post-resuscitation

Post-resuscitation brain hypoperfusion is an all too common problem following successful CPR in dogs and cats. The deterioration of neurologic status may occur, regardless of the clinician's ability to restore and maintain heart rate and rhythm, mucous membrane color, capillary refill time, and arterial blood pressure. New insight has been gained into the mechanisms responsible for post-resuscitation brain hypoperfusion, which has improved current treatment regimens and the development of new therapeutic modalities. Proper use of fluids (isotonic or hypertonic saline, oncotic solutions), diuretics, corticosteroids, and sedatives, combined with appropriate CPR techniques, can improve outcome. New drugs and therapeutic techniques offer exciting potential for the future limitation of this problem.

Functional, behavioral, and histological changes induced by transient global cerebral ischemia in rats: effects of cinnarizine and flunarizine

Temporary cerebral ischemia (15 min) produced by "four-vessel occlusion" in the rat causes neurological disorders, changes in behavior (locomotor hyperactivity), and neuronal damage in the neocortex, striatum, and especially the CA1 zone of the hippocampus. We have studied the effects of two calcium overload blockers, flunarizine (50 mg/kg p.o. twice a day) and cinnarizine (100 mg/kg p.o. twice a day), on these alterations. Cinnarizine markedly improved the functional abnormalities of ischemia but had little or no effect upon the neuronal damage. In contrast, flunarizine provided far greater neuronal protection but with less obvious effects upon behavioral parameters. However, there was evidence of sedation 2 h after treating animals with this dose of flunarizine that might have masked any positive effect of the drug on behavior. We conclude that under the present experimental conditions, there is no correlation between the early and late behavioral changes observed following a temporary cerebral ischemic episode and the histological damage observed in certain vulnerable neurons, particularly in the hippocampus, 72 h after the insult.

Effect of flunarizine on the attenuation of baroreflex by transient cerebral ischemia

Baroreflex sensitivity assessed by phenylephrine-induced reflex bradycardia was markedly decreased by 5- an 10-min global cerebral ischemia in anesthetized dogs. Flunarizine, 0.1 and 1 mg/kg i.v., administered 5 min prior to 5-min ischemia, completely inhibited the decrease in baroreflex sensitivity while such a protective effect of the latter dose was incomplete against 10-min ischemia. In contrast, papaverine, 0.5 mg/kg per min i.v., infused for 5 min prior to 5-min ischemia, failed to protect the decrease in baroreflex sensitivity. Flunarizine may possess a certain direct cerebroprotective effect in addition to its cerebrocirculatory effect.

Cerebral blood flow in humans following resuscitation from cardiac arrest

Cerebral blood flow was measured by xenon-133 washout in 13 patients 6-46 hours after being resuscitated from cardiac arrest. Patients regaining consciousness had relatively normal cerebral blood flow before regaining consciousness, but all patients who died without regaining consciousness had increased cerebral blood flow that appeared within 24 hours after resuscitation (except in one patient in whom the first measurement was delayed until 28 hours after resuscitation, by which time cerebral blood flow was increased). The cause of the delayed-onset increase in cerebral blood flow is not known, but the increase may have adverse effects on brain function and may indicate the onset of irreversible brain damage.

The physiology of cardiopulmonary resuscitation

As the pathophysiology of CPR is understood, ways to alter cerebral blood flow and neurologic outcome following CPR are likely to develop. This review highlights those areas likely to be of clinical importance in the near future.

Tolerance and pharmacokinetics of flunarizine after cardiac arrest. The Cerebral Resuscitation Study Group

Neuronal calcium overloading after complete ischemia-anoxia of the brain might be the primary process initiating chemical cascades which lead to cell death. According to this hypothesis calcium-entry blocking agents act on the final common pathway of brain damage. Flunarizine, a selective calcium-entry blocker (without influence on heart rate and on cardiac contractile force), was administered to 12 unconscious patients, recovering from cardiac arrest (CA) of cardiac origin, according to a strict dose-range infusion protocol. Blood-pressure and heart rate (HR) were recorded before, during (t = 10 min, 20 min) and after (t = 30 min, 2 h, 4 h, 6 h, 8 h) each flunarizine infusion (maximum 4 infusions). A significant, although not clinically relevant, decrease in heart rate was noted during the first infusion. Systolic (SBP) and diastolic blood pressure (DBP) also decreased during the infusion without reaching statistical significance. Plasma levels of flunarizine were determined before and after each infusion (t = 15 min, 30 min, 1 h, 2 h, 4 h, 6 h, 8 h, 12 h). Flunarizine plasma concentrations declined very rapidly after cessation of each infusion. Sequential half-lives were in the order of 11-19 min and 5-7 h, and primarily reflect rates of distribution between the systemic circulation and the rapidly equilibrating tissues such as the brain. No substantial accumulation of flunarizine was described and plasma levels were proportional to the give dose. Therefore, flunarizine pharmacokinetics can be considered as linear for doses up to 50 mg.

Flunarizine i.v. after cardiac arrest (FLUNA-study): study design and organisational aspects of a double-blind, placebo-controlled randomized study

To investigate the cerebro-protective effect of flunarizine i.v. in patients successfully resuscitated from ventricular fibrillation outside hospital, a double-blind, placebo-controlled randomized study was started in February 1988 in West-Berlin with all eight Mobile Intensive Care Units and ten major hospitals participating. Start of treatment was in the patient's home immediately after restoration of stable circulatory conditions. Primary endpoints reduction of mortality due to hypoxic brain damage and more rapid improvement after cardiac arrest and resuscitation. Inclusion criteria men and women without age limit, ventricular fibrillation prior to or upon arrival of a MICU, primarily successful cardiac resuscitation with continuing unconsciousness. Recruitment of patients will end January 31st, 1990. An inclusion of about 500 patients is expected.

Reoxygenation and calcium-induced cerebroarterial contractions as affected by vasodilator agents

In helical strips of dog cerebral arteries exposed to Ca2+-free medium under hypoxic conditions (95% N2 and 5% CO2), prostaglandin (PG) F2 alpha produced a slight tonic contraction. The addition of Ca2+ evoked a phasic contraction followed by relaxation and a sustained contraction, and reoxygenation elicited an additional tonic contraction of moderate magnitude. When the PGF2 alpha-induced contraction was stabilized in Ca2+-free medium, reoxygenation contracted the arteries only slightly. Treatment with the stable PGI2 analogues PGI2 methylester and TRK-100 attenuated the contractions caused by PGF2 alpha and Ca2+ and abolished almost completely the reoxygenation-induced contraction. Treatment with nitroglycerin inhibited the contractions caused by PGF2 alpha and Ca2+, but did not significantly alter the contraction induced by reoxygenation. The Ca2+ entry blockers diltiazem, flunarizine, and felodipine did not alter the PGF2 alpha-induced contractions, but attenuated the contractions caused by Ca2+ and reoxygenation. The vasodilator agents used appear to interfere differently with the release of Ca2+ from intracellularly stored sites and the transmembrane Ca2+ influx through receptor-operated channels under hypoxia and normoxia. The cerebroarterial contraction caused by reoxygenation may be associated mainly with increased Ca2+ influx from receptor activation and tissue oxygenation, which is markedly suppressed by PGI2 analogues and moderately attenuated by Ca2+ entry blockers but not significantly influenced by nitroglycerin.

Inability of flunarizine, lidoflazine or magnesium to counteract delayed hypoperfusion after forebrain ischaemia in the rat

Local cerebral blood flow (lCBF) was measured autoradiographically 60 min after 15 min of forebrain ischaemia in rats treated with flunarizine (0.1 mg/kg b.w.), lidoflazine (1.0 mg/kg b.w.) or Mg2+ (600 mumol/kg b.w.) before or at the end of the ischaemic period. Incomplete forebrain ischaemia was produced by a combination of common carotid artery occlusion and bleeding to a mean arterial blood pressure of 50 mmHg. During ischaemia lCBFs in cortical areas were less than 1% of preischaemic values. Neither flunarizine, lidoflazine nor Mg2+ influenced lCBF during ischaemia. Sixty minutes after the start of recirculation lCBFs were decreased to between 40 and 60% of the values found in control animals. None of the instituted treatments improved postischaemic cerebral blood flow. The results do not lend support to the view that calcium plays an essential role in the pathogenesis of delayed postischaemic hypoperfusion in the brain in this model.

Variation in serum ionized calcium on cardiopulmonary resuscitation

Changes in serum ionized calcium (Ca(++)) levels during cardiopulmonary resuscitation (CPR) and before and after CaCl(2) administration have been examined and investigated in 30 patients with cardiopulmonary arrest on arrival (dead on arrival patients) when a significant negative correlation was found to exist between the transportation time and aCa(++), as the aCa(++) level decreased with an increase in the transportation time. Upon arrival, the pH had fallen due to acidosis so that aCa(++) and cCa(++) levels were virtually normal. After admission, the pH rose as a result of CPR, resulting in a significant drop in both Ca(++) levels, so that in most cases resuscitation was not possible. Those successfully resuscitated took over 60 min to return to normal Ca(++) levels. Administration of approximately 6.6 mg/kg of CaCl(2) led to significant increases in aCa(++) and cCa(++) to essentially normal levels, even with some patients recording extremely elevated Ca levels, even with some patients recording extremely elevated Ca levels. However, the success rate of resuscitation was not found to show any significant difference according to whether CaCl(2) had or had not been administrated.Thus, it is felt necessary to re-examine the use of calcium chloride on CPR.

Brain resuscitation and protection

No drug that is used for brain protection after global brain ischaemia as a result of cardiac arrest has been shown to be of benefit. Barbiturate agents have been proved not to be beneficial whereas studies of calcium-channel blocking drugs are inconclusive. Hypothermia, haemodilution and mechanical hyperventilation are not of proven benefit. Immediate defibrillation with rapid restoration of blood pressure is the best method to improve the neurological outcome after a cardiac arrest. After severe head injury, prompt emergency care to restore ventilation, oxygenation and blood pressure improves the neurological outcome. The early evacuation of extracerebral intracranial haematomas also improves the outcome. Corticosteroid therapy does not improve the outcome. The monitoring of intracranial pressure and the control of increased intracranial pressure by hyperventilation, cerebrospinal-fluid drainage and mannitol, frusemide and barbiturate therapy appear to improve the outcome after a severe head injury, although this has not been proved by randomized controlled studies.

Effect of nimodipine-associated hypotension on recovery from acute spinal cord injury in cats

The effect of nimodipine on acute spinal cord trauma was studied in cats. Spinal evoked responses (SERs) were abolished after weight drop injury of 100 g-cm. All control animals showed spontaneous recovery of spinal cord function as measured by SERs. Treatment with a moderate intravenous dose of nimodipine resulted in a 32% drop in systemic blood pressure and delay in or failure of spinal cord recovery. We concluded that in this model, nimodipine treatment had deleterious effect on the spinal cord recovery due to the significant associated hypotension. It is likely that marked hypotension in the case of traumatic loss of autoregulation overrides the expected nimodipine-related increase in spinal cord blood flow with resultant additional ischemic damage.

Efficacy and mechanism of action of a calcium channel blocker after global cerebral ischemia in rats

Dihydropyridine calcium channel blockers such as nicardipine are under evaluation for treating acute cerebral ischemia because they may increase cerebral blood flow by causing vasodilation and because they may be cytoprotective in part by limiting production of arachidonic acid metabolites. We demonstrated in a previous study that nicardipine improves postischemic neuronal function, as measured by somatosensory evoked potentials, without reducing the extent of light-microscopic CA-1 hippocampal histologic damage. To characterize further the effect of nicardipine on global ischemic injury, we administered the drug beginning 24 hours before 30 minutes of four-vessel ischemia in Wistar rats. We then measured hippocampal ATP, phosphocreatine, and glucose contents immediately and 2 hours after ischemia, and measured learning ability (working and reference errors) on an eight-arm radial maze beginning 30 days after ischemia. To gain insight into the possible mechanism of action, we measured production of arachidonic acid metabolites (eicosanoids: TXB2 and 6-keto-PGF1 alpha) and hemispheric and hippocampal cerebral blood flow by the [14C]butanol indicator fractionation technique immediately and 2 hours after ischemia. Nicardipine was associated with fewer working errors (p less than 0.02) but no difference in reference errors. The drug had no effect on energy metabolites, cerebral blood flow, or eicosanoids immediately after ischemia, but ATP, phosphocreatine, and cerebral blood flow all returned to normal levels significantly more rapidly during reperfusion in treated rats. Nicardipine improves behavioral, electrophysiologic, and mitochondrial function after ischemia without preventing cellular damage and improves postischemic reperfusion. The drug's positive effect appears to occur during reperfusion.

Cerebral resuscitation: pathophysiology and therapy

The interest in the possibility of cerebral resuscitation has been growing exponentially during the last decade. It became clear that pharmacotherapeutic interaction can possibly alter the outcome of cerebral hypoxia/ischemia. The present review is an attempt to provide an organizational framework for a systematic integration of studies specifically dealing with pharmacological treatment post-insult.

Deterioration of conjunctival PO2 after CPR

An 82-year-old man was resuscitated following cardiac arrest suffered outside the hospital. Conjunctival oxygenation (PcjO2), as measured by a conjunctival PO2 monitor, increased in the immediate post-resuscitation period (60 min) and neurologic status improved. The PcjO2 steadily declined over the next three hours. During the period of declining PcjO2, the systolic blood pressure tended to remain stable (104 mm Hg +/- 18), the arterial PO2 (PaO2) was greater than or equal to 103 mm Hg, and the PcjO2/PaO2 ratio initially increased, while the PcjO2/arterial oxygen content (CaO2) ratio and neurologic status declined. The rise and subsequent fall of PcjO2 in this patient paralleled the neurologic status and may be consistent with the cerebral reperfusion/hypoperfusion phenomena observed in experimental preparations of resuscitation from circulatory arrest.

Regional brain calcium changes in the rat middle cerebral artery occlusion model of ischemia

Entry of Ca ions into ischemic neurons is believed to cause cell damage. Although several investigators have demonstrated changes in extracellular Ca ionic activity consistent with Ca movement into cells, direct and quantitative evidence for Ca entry into ischemic cells is lacking. We used atomic absorption spectroscopy to measure the regional distribution of tissue Ca contents of rat brains sampled at 2, 4, and 24 hours after middle cerebral artery occlusion (MCAo). At 4 hours after MCAo, Ca concentrations increased significantly (p less than 0.005) in the ischemic middle cerebral artery territory, i.e., the pyriform and frontoparietal cortices, but not in the surrounding brain. At 24 hours, Ca concentrations in the pyriform and frontoparietal cortex were respectively 30.79 (+/- 2.90) and 29.19 (+/- 3.28) mumol/g dry tissue wt compared with 11.9 (+/- 1.7) mumol/g in sham-occluded rats. Tissue Ca concentration changes in the parasagittal cortex and basal ganglia adjacent to the infarct site were much smaller and did not differ significantly from controls until 24 hours. In the ischemic middle cerebral artery territory, greater than 1.0 mumoles of Ca entered per gram of dry tissue weight per hour during the first 4 hours after MCAo. Linear regression analysis revealed a significant correlation (r = 0.9722) between changes in tissue Ca and water, with a slope indicating that 5.88 mumoles of Ca accompanied each milliliter of water entering the lesioned hemisphere. Such massive accumulations of Ca not only confirm Ca entry into injured cells, but indicate the presence of a remarkable Ca sink which sequestered within 24 hours more than 17 times the amount of free Ca present in the tissue before MCAo.

Effect of flunarizine on global brain ischemia in the dog: a quantitative morphologic assessment

The effects of flunarizine, a calcium antagonist, were evaluated in an experimental model of global brain ischemia produced by 15 min of cardiac arrest followed by resuscitation and reperfusion. One group of dogs received flunarizine (0.1 mg/kg intravenously during a 10-min period) at the onset of resuscitation. Another group of dogs underwent cardiac arrest, resuscitation, and reperfusion but did not receive flunarizine. A third group served as nonischemic control. In situ-fixed brains of all animals (nonischemic controls and the postischemic dogs after 8 h of reperfusion) were examined for anoxic ischemic injury. Quantitation of the ischemic neurons was carried out in parietal cortex, hippocampus, and cerebellum by using an image analysis system. Significant difference in the number of necrotic neurons between the flunarizine-treated group and the ischemic controls was noted in the hippocampus only; the mean percentage of necrotic neurons in the two groups being 14.8 +/- 9.6 and 29.3 +/- 12.1, respectively (P less than 0.05). These results indicate that flunarizine has an ameliorating effect on neuronal injury in the hippocampus that follows cardiac arrest in this experimental model of global brain ischemia. However, flunarizine was not found to be effective in reducing the ischemic neuronal damage in the cortex or the cerebellum.

Beagle pup model of perinatal asphyxia: nimodipine studies

Calcium antagonists may be of significant benefit in the pharmacotherapy of cerebral ischemia, possibly by improving postischemic cerebral blood flow (CBF). This study evaluated the effects of the calcium antagonist nimodipine on CBF in a newborn beagle pup model of perinatal asphyxia lasting 5 minutes. Immediately after the asphyxial episode, nimodipine (2 micrograms/kg/min) or saline was infused for 10 minutes, following which [14C]iodoantipyrine determinations of CBF were performed. In noninsulted pups, nimodipine caused both significant decreases in CBF to cortical and deep gray structures as well as a decrease in mean arterial blood pressure (MABP) (p less than 0.05). In insulted pups, nimodipine similarly decreased MABP (p less than 0.001) and CBF to cortical and deep gray matter regions. Nimodipine appeared to have no effect on arterial blood gases and EEG tracings in either insulted or noninsulted pups. Although nimodipine may be shown to improve neurologic outcome in asphyxiated newborn infants, the limits of this study do not show the mechanism to be that of improving CBF.

31P and 1H NMR spectroscopy to study the effects of gallopamil on brain ischemia

Studies were performed on 16 cats to evaluate the potential protective effects of Gallopamil on brain ischemia. Brain energy state was determined by 31P NMR and lactate concentration was determined by 1H NMR. Double-tuned surface coils (tuned to 35.8 and 88.4, respectively) were placed on the head after skin and muscle were removed from the calvarium. A 2.1-T, 25-cm-bore Oxford magnet interfaced to a Phosphoenergetics 250-80 spectrometer was used. The cats were bled to 50 mm Hg for 10 min with subsequent application of bilateral carotid occlusion for 10 min to produce ischemia. In all animals, brain energy state as measured by Pi/PCr and lactate concentrations were determined over 5-min intervals (before, during, and after the onset of ischemia). While Gallopamil did not prevent decreases in brain energy state or attenuate the rise in lactate concentration seen during ischemia, brain from animals treated with Gallopamil had a more rapid return of pHi to baseline during the recovery period. In Gallopamil-treated cats, higher levels of lactate were necessary to cause a similar decrease in pHi when compared to controls. The rate of lactate recovery to baseline levels was similar in both groups (control = -0.38 +/- 0.14 mM/min; Gallopamil = -0.44 +/- 0.32 mM/min). In conclusion, Gallopamil appears to lessen the acidosis caused by cerebral ischemia. In addition, we have demonstrated that multinuclear NMR spectroscopy is a powerful tool to study the effects of drugs on cerebral metabolism.

Comparison of thermal clearance measurement of regional cerebral blood flow with radiolabelled microspheres

A thermal clearance technique for measuring cerebral blood flow is described and compared with the radiolabelled microsphere technique. The thermal technique involves measurement of the rewarming curve generated after bolus infusion of 4-5 ml of ice-cold saline into the common carotid artery with a subdural thermistor placed on the parietal cortex. Evaluation of the biexponential decay curves obtained with this technique demonstrated a close correlation with total hemispheric, parietal, and parietal gray blood flow determined by simultaneous microsphere measurement. Despite significant correlations (p less than 0.001), scatter in the data produced a broad 95% confidence interval, thus making interpretation of blood flow with the thermal clearance technique impossible. Furthermore, instrumentation with the thermal probe, which required opening of the dura, blunted the cerebral blood flow response to hypercapnia. We conclude that the major limitations of the thermal clearance technique include: nonhomogeneous clearance function, significant variability, and depression of CO2 reactivity. These limitations must be addressed before this technique can be used reliably in the laboratory.

Prevention of gastric mucosal lesions following aortic cross-clamping

Stress ulceration is frequently encountered after cardiovascular surgery. In this study of 32 male baboons, severe gastric ischaemia was used to produce gastric stress lesions. The occurrence of these lesions was reduced by allopurinol (P = 0.03) and completely prevented by the combination of allopurinol with superoxide dismutase (P = 0.004). A shorter ischaemic period also reduced the number of lesions (P = 0.02). Concurrent with the stress lesion formation, there was a fall in mucosal glutathione and oxidized glutathione levels (P less than 0.05).

Nicardipine increases cerebral blood flow but does not improve neurologic recovery in a canine model of complete cerebral ischemia

The effects of the calcium entry blocker nicardipine on CBF, CMRO2, and neurologic outcome following 10 min of complete cerebral ischemia were examined in dogs. In CBF and CMRO2 studies, the CBF in the untreated group (seven dogs) and the nicardipine group (seven dogs; 20 micrograms kg-1 at 30 min postischemia and a subsequent infusion of 2 micrograms kg-1 min-1 for 90 min) initially increased to 300-400% and then returned to preischemic values at 30 min postischemia. Thereafter the CBF in the untreated group significantly decreased to 50% of preischemic values for the following 90-min period (hypoperfusion), while the CBF in the nicardipine group did not differ from preischemic values. The CMRO2 in both groups decreased to approximately 50-80% of preischemic values after 15 min postischemia and did not differ between the groups throughout the study. In neurologic outcome studies, 18 dogs were divided into three groups (of six dogs each): untreated; saline infusion only, posttreated; nicardipine as in CBF and CMRO2 studies, pretreated; nicardipine 20 micrograms kg-1 at 2 min preischemia and a subsequent infusion of 2 micrograms kg-1 min-1 from immediately postischemia to 120 min postischemia. Nicardipine treatment initiated either before or after ischemia failed to improve neurologic outcome at 48 h postischemia. Thus, the increase of postischemic global CBF by nicardipine is not accompanied by neurologic recovery in a canine model of complete cerebral ischemia.

Cerebral artery Doppler ultrasonography for prediction of outcome after perinatal asphyxia

43 term infants with clinical neurological manifestations of intrapartum asphyxia and who survived for more than 2 days were studied sequentially, while in hospital, with doppler ultrasound examination of the anterior cerebral arteries. 36 survivors with post-asphyxial encephalopathy were followed up for a median of 18 months and none who had had normal doppler measurements (defined by results in 49 non-asphyxiated babies) became seriously handicapped. Of the 18 infants with abnormal waveforms 12 had an adverse outcome (death or handicap). In the asphyxiated infants, doppler examination predicted outcome with an accuracy of 86%. The prediction of adverse outcome by abnormal doppler showed a sensitivity of 100% and a specificity of 81%. All abnormal results had occurred by 62 hours from birth.

Inhibition of thromboxane A2 production does not improve post-ischemic brain hypoperfusion in the dog

In a canine model of global brain ischemia, six dogs received a selective thromboxane A2 synthetase inhibitor, UK 38,485 (dazmagrel) before the ischemic event; six received a saline placebo. Cerebral blood flow (CBF), systolic and diastolic arterial pressure, cardiac output, pH, PaCO2, PaO2, and arterial and jugular-vein thromboxane B2 (a stable metabolite of thromboxane A2) and 6-keto PGF1 alpha (a stable metabolite of prostacyclin) were measured at baseline, after release of aortic and venae caval occlusion and at intervals up to 120 min thereafter. Treated animals showed nearly complete post-ischemic inhibition of thromboxane B2 production; control animals showed increases in jugular venous thromboxane B2. Arterial and jugular venous levels of 6-keto PGF1 alpha were significantly higher in treated animals at most post-ischemic intervals. CBF in both groups was similar to baseline values at time 0, then declined similarly in both groups by 30 min to approximately equal to 35% of baseline values where it remained thereafter. There were no significant differences in other variables at any interval. We conclude that inhibition of thromboxane A2 production does not alter post-ischemic brain hypoperfusion.

Should calcium be used in cardiac arrest?

Calcium salts have been recommended for and used in the treatment of various forms of cardiac arrest for many years. Although calcium plays a major role in excitation-contraction coupling, it can have a deleterious effect in some processes of cellular injury. Clinical trials suggest that calcium salts are not effective in ventricular fibrillation and asystole, but that some patients with electromechanical dissociation may have a favorable hemodynamic response. Because of the potential risks of calcium salts, their use should be limited to specific subsets of patients with cardiac arrest.

Cross-clamping of the thoracic aorta. Influence of aortic shunts, laminectomy, papaverine, calcium channel blocker, allopurinol, and superoxide dismutase on spinal cord blood flow and paraplegia in baboons

There is a high incidence of paraplegia associated with thoracic aortic cross-clamping, even when cardiopulmonary bypass or shunts are used. In 56 adult baboons, spinal cord blood flow (SCBF), vascular anatomy, and paraplegia rates were evaluated. Tissue blood flow was measured by radioactive microspheres. Various procedures were used to increase SCBF and to prevent ischemia-reperfusion injury. It was found that the rate of paraplegia was inversely correlated with neural tissue ischemia (SCBF) and directly correlated with reperfusion hyperemia. Two methods completely prevented paraplegia. These two methods were a thoracic shunt with occlusion of the infrarenal aorta or cerebrospinal fluid drainage plus intrathecal papaverine injection, both of which were associated with an increased SCBF. Furthermore, papaverine dilated the anterior spinal artery (ASA) (p = 0.007) and increased the blood flow through the lower ASA. Whereas procedures utilizing a calcium channel blocker (flunarizine), allopurinol, superoxide dismutase (SOD), laminectomy alone, and a thoracoabdominal shunt not perfusing the arteria radicularis magna (ARM) all failed to prevent paraplegia, allopurinol (p = 0.026) and SOD (p = 0.004) did prevent gastric stress lesions, indicating that their failure to prevent paraplegia was not due to a lack of activity. Of great clinical interest is that, if a shunt is used and the ARM is perfused, infrarenal aortic cross-clamping increases SCBF, thus preventing paraplegia. Intrathecal application of papaverine proved to be even more effective in increasing SCBF and also completely prevented paraplegia. As this is a safer procedure than the insertion of shunts, this is the method of choice for the prevention of paraplegia associated with thoracic aortic cross-clamping. The preliminary trial using intrathecal papaverine in human beings has thus far shown no adverse side effects from the drug, and no paraplegia has occurred.

Effect of nifedipine on cerebral high-energy phosphates after cardiac arrest and resuscitation in the rat

We studied the effect of nifedipine, a calcium entry blocker, on the recovery of cerebral adenosine triphosphate (ATP), creatine phosphate (CP), and lactate levels following resuscitation from cardiac arrest. Using the cardiac arrest and resuscitation model of de Garavilla, Babbs, and Tacker with an arrest time of eight minutes, 76% of the animals arrested were resuscitated with an average intermittent abdominal compression-CPR time of 3.3 minutes. Rats were assigned randomly to the following groups: nonischemic; eight minutes of arrest without resuscitation; and postresuscitation treatment with either IV normal saline; 3 micrograms/kg nifedipine; 10 micrograms/kg nifedipine; or 30 micrograms/kg nifedipine. Treated animals were sacrificed at either 20 or 120 minutes thereafter. As expected, after eight minutes of cardiac arrest, the levels of ATP and CP dropped to near 0 and rebounded in all resuscitated animals. By 120 minutes after resuscitation, rats given the 10-micrograms/kg dose of nifedipine had levels of ATP equivalent to nonischemic values. Return of CP values to nonischemic levels was seen only at the 3-micrograms/kg dose and was independent of time of measurement. The ATP and CP levels in these nifedipine-treated groups were significantly better when compared to saline-treated controls. There were no treatment-dependent differences in lactate levels. We conclude that clinically appropriate doses of nifedipine had a beneficial effect on the recovery of cerebral high-energy phosphates after cardiac arrest and resuscitation.

Effect of nimodipine on cerebral functional and metabolic recovery following ischemia in the rat brain

Whether the calcium entry blocker, nimodipine, prevents the increase in the concentration of free fatty acids and metabolic disturbances during ischemia and promotes functional and metabolic recovery after recirculation were examined. Severe forebrain ischemia in rats was induced by four-vessel occlusion with mild hypotension. After 30 minutes of ischemia, recirculation was started by removal of the arterial clamps and by increasing blood pressure to the preischemic level. Recovery of EEG activity following recirculation was better in the nimodipine-treated group than in the control group. During the ischemic period, there were no significant differences in accumulation of free fatty acids or in depletion of ATP between treated and control groups. At 120 minutes following recirculation, recovery of the ATP level was significantly better in the treated group than in the control group. Therefore, the promotion of functional and metabolic recovery by nimodipine-treatment is suggested to be not due to the prevention of an accumulation of free fatty acids nor to the depletion of ATP during the ischemic period, but to either improvement of postischemic hypoperfusion or a direct action on metabolic processes during reperfusion period.

Flunarizine limits hypoxia-ischemia induced morphologic injury in immature rat brain

We examined the impact of pre-treatment with the calcium antagonist flunarizine on the development of hypoxic-ischemic brain injury in the immature rat. Unilateral carotid artery ligation and subsequent exposure to 2 hours of 8% oxygen in 7-day-old rats was used as a model for perinatal hypoxic-ischemic encephalopathy. This procedure leads to atrophy in the cerebral hemisphere ipsilateral to carotid occlusion, with prominent foci of neuronal infarction in the caudate-putamen (striatum). The morphologic injury develops after 1 1/2 hours of hypoxia; and there is an equivalent time threshold for duration of hypoxic exposure needed to acutely stimulate dopamine release in the ipsilateral striatum. Parenteral administration of 30 mg/kg of flunarizine before hypoxic exposure limited both the release of dopamine acutely and the extent of morphologic damage observed two weeks after the insult. Oral administration of 30 mg/kg of flunarizine in a different vehicle prevented morphologic damage but had no effect on stimulated dopamine release. The drug vehicle for the parenteral preparation also prevented tissue injury, but to a lesser degree than flunarizine. However the parenteral vehicle was equipotent with parenteral flunarizine in limiting acute stimulation of dopamine release. The results demonstrate that flunarizine has potent neuroprotective properties against morphologic brain injury from hypoxia-ischemia, acting by a mechanism which is independent of effects on dopamine release.

The effect of carbon dioxide, lidoflazine and deferoxamine upon long term survival following cardiorespiratory arrest in rats

This study examined the effect of carbon dioxide, lidoflazine and deferoxamine therapy upon the 10-day survival incidence and subsequent neurologic function of rats subjected to 7 min of cardiorespiratory arrest with resuscitation. Cardiac arrest (asystole) was induced at time zero by injection of cold, 1% KCl into the left ventricle of ketamine-anesthetized rats pretreated with succinylcholine. Positive pressure ventilation was discontinued at time zero. Cardiopulmonary resuscitation (CPR) was begun at 7 min, and animals with return of spontaneous circulation were entered into the study. Twenty treated rats were ventilated for 1 h with 7% carbon dioxide-93% oxygen and given lidoflazine (2.0 mg/kg, i.v.) and deferoxamine (50 mg/kg, i.v.) 5 min after CPR. Twenty control rats were ventilated for 1 h with 100% oxygen and given lidoflazine vehicle and deferoxamine vehicle. Lidoflazine treatment (1.0 mg/kg) for the treated group, or lidoflazine vehicle for the control group, was repeated at 8 h postresuscitation. At 2 days postresuscitation, 75% of treated rats vs. 25% of control rats were alive (CHI2 = 10.0, d.f. = 1, P less than 0.01), and at 10 days, 60% of treated rats vs. 25% of control rats were alive (CHI2 = 5.01, d.f. = 1, P less than 0.05). There was no detectable neurologic deficit among survivors in either group at 15 days. The combination of carbon dioxide, lidoflazine and deferoxamine, administered after return of spontaneous circulation, is a simple and easily administered treatment regimen that improves the survival incidence without neurologic deficits in this animal model of cardiorespiratory arrest and CPR.

The effect of nicardipine on neuronal function following ischemia

In cerebral ischemia, it has been proposed that calcium influx into neurons results in irreversible cellular injury during reperfusion. We administered nicardipine, a dihydropyridine calcium entry blocker, by continuous subcutaneous infusion to twenty five rats beginning before (PR) or following (PO) ischemia, and compared somatosensory evoked potentials (SEPs) to twenty eight ischemic control animals. Comparable ischemic cellular changes were seen in the hippocampi of all animals. SEP amplitude was higher in both the PR (p less than .005) and PO (p less than .0005) groups compared to controls. This effect was found in all three components (P1, N1, P2) of the evoked response. Plasma nicardipine levels of 6-10 ng/ml were associated with mild hypotension. We conclude that nicardipine improved neuronal function as measured by SEPs when administered before or after ischemia, most likely by interrupting the cytotoxic events occurring in cortical neurons during reperfusion.

A history of resuscitation

In the 1950s, researchers devised the best methods of ventilation. In the 1960s, a method of maintaining circulation and ventilation simultaneously was introduced. In the 1970s, refinements of the understanding of the mechanisms of blood flow during CPR were defined and were accompanied by an aggressive research effort to identify means to improve brain protection during and after cardiac arrest. It is hoped that the fruits of this work will lead to knowledge of better ways to effect resuscitation and will maximize the quality of life in survivors of cardiac arrest.