Is deep hypothermia necessary for unilateral antegrade cerebral perfusion during circulatory arrest? A magnetic resonance study in a pig model

A modified protocol for retrograde cerebral perfusion: magnetic resonance spectroscopy in pigs

OBJECTIVES

Retrograde cerebral perfusion (RCP) has been employed to protect the brain during cardiovascular surgery, requiring temporary hypothermic circulatory arrest (HCA). However, the protocol used for RCP remains to be modified if prolonged HCA is expected. The aim of this study was to determine the efficacy of a modified protocol for this purpose.

METHODS

After establishment of HCA at 15°C, 14 pigs were subjected to 90-min RCP using either the conventional protocol (i.e. alpha-stat strategy, 25-mmHg perfusion pressure and occluded inferior vena cava, Group I, n = 7) or the new protocol (i.e. pH-stat strategy, 40-mmHg perfusion pressure and unoccluded inferior vena cava, Group II, n = 7). After being rewarmed to 37°C, pigs were perfused for another 60 min. Phosphorus-31 magnetic resonance spectroscopy was used to track the changes of brain high-energy phosphates [i.e. adenosine triphosphate and phosphocreatine (PCr)] and intracellular pH (pHi). At the end, brain water content was measured.

RESULTS

During RCP, high-energy phosphates decreased in both groups, whereas adenosine triphosphate decreased much faster in Group I (10.4 ± 4.3 vs 30.4 ± 4.4% of the baseline, P = 0.007, 60-min RCP). After rewarming, the recovery of high-energy phosphates and pHi was much slower in Group I (PCr: 55.7 ± 9.1 vs 78.4 ± 5.1% of the baseline, P = 0.046; adenosine triphosphate: 26.6 ± 10.6 vs 64.8 ± 4.6% of the baseline, P = 0.007; pHi: 6.5 ± 0.4 vs 7.1 ± 0.1, P = 0.021 at 30-min normothermic perfusion after rewarming). Brain tissue water content was significantly higher in Group I (81.1 ± 0.4 vs 79.5 ± 0.4%, P = 0.016).

CONCLUSIONS

Application of the modified RCP protocol significantly improved cerebral energy conservation during HCA and accelerated energy recovery after rewarming.

Cerebrovascular response to continuous cold perfusion and hypothermic circulatory arrest

OBJECTIVE

Clinical and laboratory studies have documented changes in cerebrovascular resistance after hypothermic circulatory arrest, both with and without adjunctive cerebral perfusion modalities. This study was designed to clarify whether these changes are due to cerebral edema, resistance vessel abnormalities, or alterations in the cerebral microcirculation.

METHODS

Four mature swine underwent hypothermic circulatory arrest for 60 minutes, and 7 mature swine underwent cold cerebral perfusion for 60 minutes to simulate antegrade selective perfusion. All were rewarmed and weaned from cardiopulmonary bypass. Pial vascular diameter and reactivity were measured in vivo through a cranial window and ex vivo in an organ chamber; cerebral microvascular endothelium was studied in culture for release of vasoactive mediators. Cerebral water content was recorded.

RESULTS

Cold perfusion caused pial arteriole and venule constriction, whereas hypothermic circulatory arrest alone caused pial arteriole and venule dilatation. Cold perfusion caused a temporal loss of endothelium-dependent vasodilatation, most notably to bradykinin. Hypothermic circulatory arrest caused a loss of nitric oxide-mediated endothelium-dependent vasodilatation. Endothelium-independent vasoreactivity remained intact in both groups. Endothelial cells from the cold group had a vasoconstrictive secretory phenotype, whereas endothelial cells from the hypothermic circulatory arrest group had a vasodilatory phenotype. Cerebral water content was the same in both groups.

CONCLUSION

The increase in cerebrovascular resistance observed after cold cerebral perfusion is caused by resistance vessel constriction and may be promoted by an altered microcirculation. Hypothermic circulatory arrest alone is associated with endothelium-dependent vasoparesis. Both could contribute to cerebral injury in the early hours after operation.

Mast cell-derived mediators protect against oxygen-glucose deprivation-induced injury in PC12 cells and neurons

Recent reports and our previous study suggest that mast cells play a crucial role in the pathological processes that follow cerebral ischemia. In this study, the effect of mast cells on neuron injury after cerebral ischemia was determined by adding in vitro ischemia-induced supernatant from mast cells to neurons and PC12 cells under the same conditions (oxygen-glucose deprivation, OGD). The degree of cell injury was evaluated by the 3-[4,5-dimethylthiazol-2-yl]-2,5-dipheny-ltetrazolium bromide (MTT) assay. Mast cell-derived supernatant protected against OGD-induced injury of PC12 cells and neurons, and this protection was reversed by a histamine H1 antagonist and by anti-histamine serum, but not by an H2 antagonist. However, histamine and nerve growth factor (NGF) added separately or together did not have protective effects against OGD-induced injury. These results indicate that mast cell-derived protection during in vitro ischemia is histamine-dependent, and involves cooperation with other mediators, but not NGF.