Pressor response to pulsatile compression of the rostral ventrolateral medulla mediated by nitric oxide and c-fos expression

Differential impacts of brain stem oxidative stress and nitrosative stress on sympathetic vasomotor tone

Based on work-done in the rostral ventrolateral medulla (RVLM), this review presents four lessons learnt from studying the differential impacts of oxidative stress and nitrosative stress on sympathetic vasomotor tone and their clinical and therapeutic implications. The first lesson is that an increase in sympathetic vasomotor tone because of augmented oxidative stress in the RVLM is responsible for the generation of neurogenic hypertension. On the other hand, a shift from oxidative stress to nitrosative stress in the RVLM underpins the succession of increase to decrease in sympathetic vasomotor tone during the progression towards brain stem death. The second lesson is that, by having different cellular sources, regulatory mechanisms on synthesis and degradation, kinetics of chemical reactions, and downstream signaling pathways, reactive oxygen species and reactive nitrogen species should not be regarded as a singular moiety. The third lesson is that well-defined differential roles of oxidative stress and nitrosative stress with distinct regulatory mechanisms in the RVLM during neurogenic hypertension and brain stem death clearly denote that they are not interchangeable phenomena with unified cellular actions. Special attention must be paid to their beneficial or detrimental roles under a specific disease or a particular time-window of that disease. The fourth lesson is that, to be successful, future antioxidant therapies against neurogenic hypertension must take into consideration the much more complicated picture than that presented in this review on the generation, maintenance, regulation or modulation of the sympathetic vasomotor tone. The identification that the progression towards brain stem death entails a shift from oxidative stress to nitrosative stress in the RVLM may open a new vista for therapeutic intervention to slow down this transition.

Intracranial mechanisms for preserving brain blood flow in health and disease

The brain is an exceptionally energetically demanding organ with little metabolic reserve, and multiple systems operate to protect and preserve the brain blood supply. But how does the brain sense its own perfusion? In this review, we discuss how the brain may harness the cardiovascular system to counter threats to cerebral perfusion sensed via intracranial pressure (ICP), cerebral oxygenation and ischaemia. Since the work of Cushing over 100 years ago, the existence of brain baroreceptors capable of eliciting increases in sympathetic outflow and blood pressure has been hypothesized. In the clinic, this response has generally been thought to occur only in extremis, to perfuse the severely ischaemic brain as cerebral autoregulation fails. We review evidence that pressor responses may also occur with smaller, physiologically relevant increases in ICP. The incoming brain oxygen supply is closely monitored by the carotid chemoreceptors; however, hypoxia and other markers of ischaemia are also sensed intrinsically by astrocytes or other support cells within brain tissue itself and elicit reactive hyperaemia. Recent studies suggest that astrocytic oxygen signalling within the brainstem may directly affect sympathetic nerve activity and blood pressure. We speculate that local cerebral oxygen tension is a major determinant of the mean level of arterial pressure and discuss recent evidence that this may be the case. We conclude that intrinsic intra- and extra-cranial mechanisms sense and integrate information about hypoxia/ischaemia and ICP and play a major role in determining the long-term level of sympathetic outflow and arterial pressure, to optimize cerebral perfusion.

Is hypertension a risk factor of hemifacial spasm?

OBJECTIVES

The published data on the relation between arterial hypertension (AH) and hemifacial spasm (HFS) are controversial. The aim of the study was to determine the prevalence of AH in HFS patients and the relation of AH and compression of the brainstem at the region of vasomotor center.

MATERIALS AND METHODS

The study included 60 of primary HFS patients and 60 healthy controls matched by age. AH was defined according to WHO criteria. The vessel compression of the brainstem was measure on MRI scans in selected region of vasomotor center located in the ventro-lateral medulla (VLM), between the pontomedullary junction, retro-olivary sulcus and the root entry zone (REZ) of the IX and X nerves. Modeling and compression severity of the VLM was graded in the 0-3 scale.

RESULTS

The prevalence of AH in HFS patients did not differ significantly from the control group (61.6% vs 45.0%, p=ns). VML compression by vessel was frequently found in HFS patients with AH than without AH (97.2% vs 60.9%, χ(2)=11.0, p=0.0009). A similar relation was also found in the control group. The higher rate of VML vascular compression was related to the presence of AH in both, HFS patients and control group.

CONCLUSION

The prevalence of AH in HFS patients does not differ from controls. The VLM compression in HFS patients and controls is related to AH diagnosis. The association between AH and VLM compression is stronger in patients with higher degree of VLM compression.

Altered neural and vascular mechanisms in hypertension

Essential hypertension is a multifactorial disorder which belongs to the main risk factors responsible for renal and cardiovascular complications. This review is focused on the experimental research of neural and vascular mechanisms involved in the high blood pressure control. The attention is paid to the abnormalities in the regulation of sympathetic nervous system activity and adrenoceptor alterations as well as the changes of membrane and intracellular processes in the vascular smooth muscle cells of spontaneously hypertensive rats. These abnormalities lead to increased vascular tone arising from altered regulation of calcium influx through L-VDCC channels, which has a crucial role for excitation-contraction coupling, as well as for so-called "calcium sensitization" mediated by the RhoA/Rho-kinase pathway. Regulation of both pathways is dependent on the complex interplay of various vasodilator and vasoconstrictor stimuli. Two major antagonistic players in the regulation of blood pressure, i.e. sympathetic nervous system (by stimulation of adrenoceptors coupled to stimulatory and inhibitory G proteins) and nitric oxide (by cGMP signaling pathway), elicit their actions via the control of calcium influx through L-VDCC. However, L-type calcium current can also be regulated by the changes in membrane potential elicited by the activation of potassium channels, the impaired function of which was detected in hypertensive animals. The dominant role of enhanced calcium influx in the pathogenesis of high blood pressure of genetically hypertensive animals is confirmed not only by therapeutic efficacy of calcium antagonists but especially by the absence of hypertension in animals in which L-type calcium current was diminished by pertussis toxin-induced inactivation of inhibitory G proteins. Although there is considerable information on the complex neural and vascular alterations in rats with established hypertension, the detailed description of their appearance during the induction of hypertension is still missing.

Nitric oxide in rostral ventrolateral medulla regulates cardiac-sympathetic reflexes: role of synthase isoforms

Our previous studies have shown that nitric oxide (NO) synthase (NOS)-containing neurons in the rostral ventrolateral medulla (rVLM) are activated during cardiac sympathoexcitatory reflexes (Refs. 12 and 13). However, the precise function of NO in the rVLM in regulation of these reflexes has not been defined. Three isoforms of NOS, including neuronal NOS (nNOS), inducible NOS (iNOS), and endothelial NOS (eNOS), are located in the rVLM. We explored the role of NO, derived from different NOS isoforms in the rVLM, in processing cardiac-sympathetic reflexes using whole animal reflex and electrophysiological approaches. We found that, in anesthetized cats, increased mean arterial blood pressure and renal sympathetic nerve activity elicited by epicardial application of bradykinin (BK; 1-10 microg/ml, 50 microl) were significantly attenuated following unilateral rVLM microinjection of the nonselective NOS inhibitor, N(omega)-nitro-L-arginine methyl ester (50 nmol/50 nl), or a specific nNOS inhibitor, 7-nitroindazole (7-NI; 5-10 pmol/50 nl; both P < 0.05). In contrast, the responses of mean arterial blood pressure and renal sympathetic nerve activity to cardiac BK stimulation were unchanged by unilateral rVLM microinjection of N(omega)-nitro-D-arginine methyl ester (inactive isomer of N(omega)-nitro-L-arginine methyl ester, 50 nmol/50 nl), 3-6% methanol (7-NI vehicle), N(6)-(1-iminoethyl)-L-lysine (250 pmol/50 nl; iNOS inhibitor), or N(5)-(1-iminoethyl)-L-ornithine (250 nmol/50 nl; eNOS inhibitor). Furthermore, in separate cats, we noted that iontophoresis of 7-NI (0.1 mM) reduced the increased discharge of cardiovascular sympathoexcitatory rVLM neurons in response to cardiac stimulation with BK (P < 0.05). These neurons were characterized by their responses to inputs from baroreceptors, and their cardiac rhythmicity was determined through frequency and time domain analyses, correlating their discharge to arterial blood pressure and cardiac sympathetic efferent nerve activity. These data suggest that NO, specifically nNOS, mediates sympathetic cardiac-cardiovascular responses through its action in the rVLM.

Autonomic neurosurgery: from microvascular decompression to image guided stimulation

The paper reviews mechanisms underlying autonomic disorders, with a focus on cardiovascular dysfunction. Neurosurgical approaches are described for medically refractory hypertension and orthostatic hypotension. After review of microvascular decompression of the rostral ventrolateral medulla, stereotactic CT and MRI guided deep brain stimulation of the periaqueductal grey matter (PAG) is evaluated. Results are presented from patient studies showing reductions in blood pressure with ventral PAG stimulation and increases in blood pressure with dorsal PAG stimulation. A rationale for the treatment of autonomic disorders by neurosurgical intervention is discussed.

The spectrum of magnetic resonance imaging findings in hypertension-related neurovascular compression

Hypertension (HTN) has been controversially related to neurovascular compression (NVC) at the rostral ventrolateral (RVL) medulla in anatomical, surgical, and radiological reports. Our objective was to investigate the association between primary HTN and signs of NVC at the medulla oblongata on magnetic resonance imaging (MRI) and to explore a new classification based on image criteria. Subjects with (n=64) and without (n=29) HTN were studied. Three-millimeter slices, with 1-mm intervals in between, were performed on T2-weighted images in axial and coronal views. Attention was focused on the relationship between the upper medulla and the surrounding arteries. The findings were divided into three categories: 1) non-NVC: absence of signs of NVC, 2) NVC type I: an artery in contact with the RVL medulla but not compressing it, and 3) NVC type II: evident compression of the RVL medulla by an artery. Signs of NVC were observed in 65.7% (42/64) of the HTN group (type I: 39.1%, 25/42 patients; type II: 26.6%, 17/42 patients). Among the normotensive subjects, 27.6% (8/29) had signs of NVC; only one (3.3%) of these had NVC type II (evident compression), and the rest were NVC type I. We conclude that the presence of NVC at the RVL medulla on MRI is related to HTN. More importantly, the finding of frank compression (NVC type II) is present almost exclusively in hypertensive subjects; only one individual (3.3% of our normotensive population) had NVC type II.

New insights on brain stem death: From bedside to bench

As much as brain stem death is currently the clinical definition of death in many countries and is a phenomenon of paramount medical importance, there is a dearth of information on its mechanistic underpinnings. A majority of the clinical studies are concerned only with methods to determine brain stem death. Whereas a vast amount of information is available on the cellular and molecular mechanisms of cell death, rarely are these studies directed specifically towards the understanding of brain stem death. This review presents a framework for translational research on brain stem death that is based on systematically coordinated clinical and laboratory efforts that center on this phenomenon. It begins with the identification of a novel clinical marker from patients that is related specifically to brain stem death. After realizing that this "life-and-death" signal is related to the functional integrity of the brain stem, its origin is traced to the rostral ventrolateral medulla (RVLM). Subsequent laboratory studies on this neural substrate in animal models of brain stem death provide credence to the notion that both "pro-life" and "pro-death" programs are at work during the progression towards death. Those programs (mitochondrial functions, nitric oxide, peroxynitrite, superoxide anion, coenzyme Q10, heat shock proteins and ubiquitin-proteasome system) hitherto identified from the RVLM are presented, along with their cellular and molecular mechanisms. It is proposed that outcome of the interplay between the "pro-life" and "pro-death" programs (dying) in this neural substrate determines the final fate of the individual (being dead). Thus, identification of additional programs in the RVLM and delineation of their regulatory mechanisms should shed new lights on future directions for clinical management of life-and-death.

HYPOTHESIS: SET-POINTS and LONG-TERM CONTROL OF ARTERIAL PRESSURE. A THEORETICAL ARGUMENT FOR A LONG-TERM ARTERIAL PRESSURE CONTROL SYSTEM IN THE BRAIN RATHER THAN THE KIDNEY

1. It has been hypothesised that the 'set-point' for the long-term control of mean arterial (MAP) resides within the kidney. In this model, the set-point of the 'chronic renal function curve' establishes the steady state relationship between renal perfusion pressure and urinary excretion of sodium and water, which, in turn, affects blood volume and cardiac output. The 'renal-MAP set-point' theory predicts that the kidney controls MAP to maintain its own excretory function and that long-term regulation of blood volume and cardiac output are paramount to the regulation of arterial pressure. 2. An alternative hypothesis is proposed in which the 'set-point' for the long-term control of MAP resides within the central nervous system (CNS) rather than the kidney. In contrast with the 'renal-MAP set-point' model, the 'CNS-MAP set-point' model dictates that the brain controls MAP to maintain cerebral blood flow and CNS function. 3. The 'CNS-MAP set-point hypothesis' predicts that long-term regulation of MAP is paramount to the regulation of blood volume and cardiac output. It is proposed that the 'CNS-MAP set-point' system operates independently of the arterial baroreceptor reflex, which is a short-term controller of MAP. 4. The precise mechanisms by which the CNS 'senses' MAP are complex and remain to be discovered. The MAP 'sensor' likely involves integration of hormone levels linked to body fluid homeostasis and osmoreceptor and baroreceptor inputs. It is also proposed that an as yet undiscovered 'central baroreceptor' exists within the brain itself. 5. The 'CNS-MAP set-point hypothesis' predicts that many forms of experimental and essential hypertension are due to a primary shift in the CNS-MAP set-point.

Adrenomedullin in the rostral ventrolateral medulla increases arterial pressure and heart rate: roles of glutamate and nitric oxide

This study was done to investigate the effects of microinjections of adrenomedullin (ADM), a vasoactive neuropeptide, in the rostral ventrolateral medulla (RVLM) on mean arterial pressure (MAP) and heart rate (HR) in urethane-anesthetized rats, and to assess the potential roles of glutamate and nitric oxide (NO) in these effects. Unilateral injections of ADM (0.01 or 0.1 pmol) into the RVLM significantly increased MAP and HR in a dose-dependent manner, whereas ADM at 0.001 pmol was ineffective. Microinjections of ADM (0.01 pmol) outside the RVLM had no effects on MAP or HR. Coinjections of a putative ADM receptor antagonist, ADM(22-52) (0.01 pmol), abolished the increases in MAP and HR evoked by ADM (0.01 pmol). The vasopressor effects of ADM (0.01 pmol) in the RVLM were abolished by coinjections of either dizocilpine hydrogen maleate (a selective NMDA glutamate receptor antagonist, 500 pmol) or 6-cyano-7-nitroquinoxaline-2,3-dione (a selective non-NMDA glutamate receptor antagonist, 50 pmol). The ADM-induced vasopressor effects were also abolished by coadministration of either 7-nitroindazole sodium salt (a selective neuronal NO synthase inhibitor, 0.05 pmol) or methylene blue (a soluble guanylyl cyclase inhibitor, 100 pmol). These results suggest that ADM in the RVLM stimulates increases in MAP and HR through ADM receptor-mediated mechanisms. These effects are mediated by glutamate via both NMDA and non-NMDA receptors. NO, derived from neuronal NO synthase, also contributes to the ADM-induced vasopressor effects via a soluble guanylyl cyclase-associated signaling pathway.

Brainstem mechanisms of hypertension: role of the rostral ventrolateral medulla

The central nervous system plays a key role in the regulation of cardiovascular function, and alterations in the central neural mechanisms that control blood pressure may underlie the vast majority of cases of primary hypertension. The well-studied baroreceptor reflex powerfully regulates arterial pressure, though its involvement in the pathogenesis of chronic hypertension is likely to be only of minor importance. Supraspinal maintenance of sympathetic vasomotor outflow appears to emanate from neurons in the rostral ventrolateral medulla, and the tonic drive exerted on sympathetic vasomotor activity by the rostral ventrolateral medulla appears to be increased in several animal models of hypertension. In particular, the excitation of the rostral ventrolateral medulla by excitatory amino acid neurotransmitters and by stimulation of AT(1) angiotensin receptors appears to be increased in experimental hypertension. The current data support the view that neurogenic hypertension is mediated by increased excitatory drive of rostral ventrolateral medulla sympathoexcitatory neurons.

Downregulation of basal iNOS at the rostral ventrolateral medulla is innate in SHR

We demonstrated recently that a significant reduction in both the molecular synthesis and functional expression of inducible nitric oxide synthase (iNOS) in the rostral ventrolateral medulla (RVLM), the medullary origin of sympathetic vasomotor outflow, underlies the augmented sympathetic vasomotor tone during hypertension. This study further evaluated the hypothesis that this downregulation of basal iNOS at the RVLM during hypertension is innate. In adult spontaneously hypertensive rats (SHR) treated for 4 weeks with the antihypertensive captopril to normalize elevated blood pressure or in young prehypertensive SHR, the significantly lower iNOS mRNA and protein levels at the ventrolateral medulla under basal conditions or on activation by microinjection bilaterally into the RVLM of lipopolysaccharide (10 ng) remained unaltered. The retarded efficacy of lipopolysaccharide (10 ng) to elicit cardiovascular depression (hypotension, bradycardia, and reduction in sympathetic vasomotor tone) also persevered in captopril-treated adult or young normotensive SHR. On the other hand, compared with Wistar-Kyoto normotensive rats, the magnitude of cardiovascular depression induced in adult SHR by local administration into the RVLM of the NO precursor l-arginine (40 nmol) was significantly smaller. In addition, microinjection bilaterally into the RVLM of a selective iNOS inhibitor, aminoguanidine (125 or 250 pmol), was discernibly less efficacious in unmasking hypertension, tachycardia, and the increase in sympathetic vasomotor tone in adult SHR. We conclude that a predisposed reduction in molecular synthesis and functional expression of basal iNOS in the RVLM is associated with the sympathetic vasomotor overactivity during hypertension.

Differential engagements of glutamate and GABA receptors in cardiovascular actions of endogenous nNOS or iNOS at rostral ventrolateral medulla of rats

1. We evaluated in Sprague-Dawley rats anaesthetized with propofol the engagement of soluble guanylyl cyclase (sGC)/cGMP cascade, glutamatergic and GABAergic neurotransmission in the cardiovascular actions of endogenous nitric oxide (NO) at the rostral ventrolateral medulla (RVLM). 2. Microinjection bilaterally into the RVLM of a selective iNOS inhibitor, S-methylisothiourea (SMT, 250 pmoles), or a selective nNOS inhibitor, 7-nitroindazole (7-NI, 5 pmoles), induced respectively an enhancement or a reduction in systemic arterial pressure, heart rate and power density of the vasomotor components in the spectrum of arterial blood pressure signals, our experimental index for sympathetic neurogenic vasomotor tone. 3. The cardiovascular actions of SMT or 7-NI in the RVLM were significantly antagonized by co-administration into the RVLM of the sGC inhibitor, 1H-[1,2,4]Oxadiazole[4,3-alpha]quinoxalin-1-one (ODQ, 250 or 500 pmoles). 4. The cardiovascular excitatory effects after blockade of endogenous iNOS activity were significantly attenuated when N-methyl-D-aspartate (NMDA) receptor antagonist, dizocilpine (20 or 50 pmoles), or non-NMDA receptor antagonist, 6-cyano-7-nitroquinoxaline-2,3-dione (250 or 500 pmoles), was co-microinjected bilaterally into the RVLM. 5. On the other hand, the cardiovascular depressive responses to blockade of endogenous nNOS activity were significantly antagonized on co-administration of GABA(A) receptor antagonist, bicuculline methiodine (5 or 10 pmoles), but not GABA(B) receptor antagonist, 2-hydroxy saclofen (50 or 100 pmoles). 6. We conclude that the cardiovascular actions of endogenous NO in the RVLM engage the sGC/cGMP pathway. In addition, whereas NO derived from nNOS induced sympathoexcitation via both NMDA and non-NMDA receptors in the RVLM, NO generated by iNOS elicited sympathoinhibition via GABA(A) receptors.

Baroreceptor reflex pathways and neurotransmitters: 10 years on

The central nervous system plays a critical role in the management of blood flow to the tissues and its return to the heart and lungs. This is achieved by a complex interplay of neural efferent pathways, humoral mechanisms and afferent pathways. In this review, we focus on recent progress (within the past 10 years) that has been made in the sympathetic control of arterial blood pressure with a special emphasis on the role of baroreceptor mechanisms and central neurotransmitters. In particular, we focus on new features since 1991, such as neurotransmission in the nucleus tractus solitarius, the role of neurons in the most caudal part of the ventrolateral medulla oblongata and the increasing understanding of the exquisite control of different sympathetic pathways by different neurotransmitter systems.