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Xiong L, Chen X, Liu J, Wong LKS, Leung TW. Cerebral Augmentation Effect Induced by External Counterpulsation Is Not Related to Impaired Dynamic Cerebral Autoregulation in Ischemic Stroke. Front Neurol 2022; 13:784836. [PMID: 35592467 PMCID: PMC9110640 DOI: 10.3389/fneur.2022.784836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose Dynamic cerebral autoregulation is impaired after ischemic stroke. External counterpulsation (ECP) augments the cerebral blood flow of patients with ischemic stroke by elevation of blood pressure (BP). We aimed to investigate if cerebral augmentation effects during ECP were associated with impaired dynamic cerebral autoregulation in patients after acute ischemic stroke. Methods Forty patients with unilateral ischemic stroke and large artery atherosclerosis in the anterior circulation territory within 7 days from symptom onset and eighteen healthy controls were recruited. We monitored changes in mean flow velocity over both middle cerebral arteries (MCA) by transcranial Doppler (TCD) before, during, and immediately after ECP. Cerebral augmentation index was MCA mean flow velocity increase in percentage during ECP compared with baseline to evaluate the augmentation effects of ECP. Spontaneous arterial BP and cerebral blood flow velocity in both bilateral MCAs were recorded using a servo-controlled plethysmograph and TCD, respectively. Transfer function analysis was used to derive the autoregulatory parameters, including phase difference (PD), and gain. Results The cerebral augmentation index in patients with stroke was significantly higher on both the ipsilateral and contralateral sides than that in controls, while the PD in patients with stroke was significantly lower on both sides than those in controls (all P < 0.05). The cerebral augmentation index did not correlate with PD and gain on either the ipsilateral or contralateral side of patients with stroke or in controls (all P > 0.05). The cerebral augmentation index of patients with stroke was significantly related to mean BP change on the ipsilateral side (R2 = 0.108, P = 0.038). Conclusion The degree of ECP-induced cerebral augmentation effects as measured by the cerebral augmentation index did not correlate with the magnitude of impaired dynamic cerebral autoregulation.
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Affiliation(s)
- Li Xiong
- Clinical Trials Centre, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- *Correspondence: Li Xiong
| | - Xiangyan Chen
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Shatin, Hong Kong SAR, China
- Xiangyan Chen
| | - Jia Liu
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Lawrence Ka Sing Wong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Thomas W. Leung
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
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Hilz MJ, Wang R, Marthol H, Liu M, Tillmann A, Riss S, Hauck P, Hösl KM, Wasmeier G, Stemper B, Köhrmann M. Partial pharmacologic blockade shows sympathetic connection between blood pressure and cerebral blood flow velocity fluctuations. J Neurol Sci 2016; 365:181-7. [PMID: 27206903 DOI: 10.1016/j.jns.2016.04.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 03/24/2016] [Accepted: 04/07/2016] [Indexed: 11/18/2022]
Abstract
Cerebral autoregulation (CA) dampens transfer of blood pressure (BP)-fluctuations onto cerebral blood flow velocity (CBFV). Thus, CBFV-oscillations precede BP-oscillations. The phase angle (PA) between sympathetically mediated low-frequency (LF: 0.03-0.15Hz) BP- and CBFV-oscillations is a measure of CA quality. To evaluate whether PA depends on sympathetic modulation, we assessed PA-changes upon sympathetic stimulation with and without pharmacologic sympathetic blockade. In 10 healthy, young men, we monitored mean BP and CBFV before and during 120-second cold pressor stimulation (CPS) of one foot (0°C ice-water). We calculated mean values, standard deviations and sympathetic LF-powers of all signals, and PAs between LF-BP- and LF-CBFV-oscillations. We repeated measurements after ingestion of the adrenoceptor-blocker carvedilol (25mg). We compared parameters before and during CPS, without and after carvedilol (analysis of variance, post-hoc t-tests, significance: p<0.05). Without carvedilol, CPS increased BP, CBFV, BP-LF- and CBFV-LF-powers, and shortened PA. Carvedilol decreased resting BP, CBFV, BP-LF- and CBFV-LF-powers, while PAs remained unchanged. During CPS, BPs, CBFVs, BP-LF- and CBFV-LF-powers were lower, while PAs were longer with than without carvedilol. With carvedilol, CPS no longer shortened resting PA. Sympathetic activation shortens PA. Partial adrenoceptor blockade abolishes this PA-shortening. Thus, PA-measurements provide a subtle marker of sympathetic influences on CA and might refine CA evaluation.
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Affiliation(s)
- Max J Hilz
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany.
| | - Ruihao Wang
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany.
| | - Harald Marthol
- Department of Psychiatry, Addiction, Psychotherapy and Psychosomatics, Klinikum am Europakanal, Am Europakanal 71, 91056 Erlangen, Germany.
| | - Mao Liu
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany.
| | - Alexandra Tillmann
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany.
| | - Stephan Riss
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany.
| | - Paulina Hauck
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany.
| | - Katharina M Hösl
- Department of Psychiatry and Psychotherapy, Paracelsus Medical University Nuremberg, Prof.-Ernst-Nathan-Strasse 1, 90419 Nuremberg, Germany.
| | - Gerald Wasmeier
- Department of Cardiology, Klinik Neustadt a. d. Aisch, Paracelsusstraße 30-36, 91413 Neustadt a. d. Aisch, Germany.
| | - Brigitte Stemper
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany; Bayer HealthCare, Bayer Pharma AG, Global Development Specialty Medicine, Müllerstr. 178, Building P300, Room 239, 13353 Berlin, Germany.
| | - Martin Köhrmann
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany.
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Transfer function analysis for the assessment of cerebral autoregulation using spontaneous oscillations in blood pressure and cerebral blood flow. Med Eng Phys 2014; 36:563-75. [DOI: 10.1016/j.medengphy.2014.02.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 01/31/2014] [Accepted: 02/03/2014] [Indexed: 12/21/2022]
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Lin W, Xiong L, Han J, Leung H, Leung T, Soo Y, Chen X, Wong KSL. Increasing pressure of external counterpulsation augments blood pressure but not cerebral blood flow velocity in ischemic stroke. J Clin Neurosci 2013; 21:1148-52. [PMID: 24508283 DOI: 10.1016/j.jocn.2013.09.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 09/04/2013] [Accepted: 09/24/2013] [Indexed: 11/29/2022]
Abstract
External counterpulsation (ECP) is a noninvasive method used to augment cerebral perfusion but the optimal use of ECP in ischemic stroke has not been well documented. We aimed to investigate the effects of ECP treatment pressure on cerebral blood flow and blood pressure (BP). We recruited 38 ischemic stroke patients with large artery occlusive disease and 20 elderly controls. We commenced ECP treatment pressure at 150 mmHg and gradually increased to 187.5, 225 and 262.5 mmHg. Mean cerebral blood flow velocities (CBFV) of bilateral middle cerebral arteries and continuous beat-to-beat BP were recorded before ECP and during each pressure increment for 3 minutes. Patient CBFV data was analyzed based on whether it was ipsilateral or contralateral to the infarct. Mean BP significantly increased from baseline in both stroke and control groups after ECP commenced. BP increased in both groups following raised ECP pressure and reached maximum at 262.5 mmHg (patients 16.9% increase versus controls 16.52%). The ipsilateral CBFV of patients increased 5.15%, 4.35%, 4.55% and 3.52% from baseline under the four pressures, respectively. All were significantly higher than baseline but did not differ among different ECP pressures; contralateral CBFV changed likewise. Control CBFV did not increase under variable pressures of ECP. ECP did increase CBFV of our patients to a roughly equal degree regardless of ECP pressure. Among the four ECP pressures tested, we recommend 150 mmHg as the optimal treatment pressure for ischemic stroke due to higher risks of hypertension-related complications with higher pressures.
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Affiliation(s)
- Wenhua Lin
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region
| | - Li Xiong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region
| | - Jinghao Han
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region
| | - Howan Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region
| | - Thomas Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region
| | - Yannie Soo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region
| | - Xiangyan Chen
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region
| | - Ka Sing Lawrence Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region.
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Saqqur M, Ibrahim M, Butcher K, Khan K, Emery D, Manawadu D, Derksen C, Schwindt B, Shuaib A. Transcranial Doppler and Cerebral Augmentation in Acute Ischemic Stroke. J Neuroimaging 2012; 23:460-5. [DOI: 10.1111/j.1552-6569.2011.00674.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Enhanced external counterpulsation and traction therapy ameliorates rotational vertebral artery flow insufficiency resulting from cervical spondylosis. Spine (Phila Pa 1976) 2010; 35:1415-22. [PMID: 20098348 DOI: 10.1097/brs.0b013e3181c62956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Clinical trial of patients with rotational vertebrobasilar insufficiency (VBI) resulting from cervical spondylosis. OBJECTIVE To investigate the effectiveness of enhanced external counterpulsation (EECP) and traction therapy for these patients. SUMMARY OF BACKGROUND DATA EECP would reduce arterial stiffness and vascular resistance, and increase regional blood flow of vertebral arteries, thus may ameliorate symptoms in these patients. METHODS One hundred sixty-three patients who were clinically suspected rotational VBI caused by cervical spondylosis were enrolled in this study. They were randomly allocated into 3 groups: EECP + traction, EECP, and traction group. All patients and 50 healthy volunteers received transcranial color Doppler examination of the vertebral artery and basilar artery in both a neutral cervical spine position and a rotational position. RESULTS Within 3 days after treatment, 47 (84%) patients in EECP + traction group, 32 (61%) patients in EECP group, and 8 (15%) patients in traction group achieved successful outcomes, while at 3 months' follow-up, 45 (80%) patients in EECP + traction group, 34 (64%) in EECP group, and 3 (6%) in traction group achieved successful outcomes. With head rotation, the percentage of reduction of blood flow velocities of the vertebrobasilar artery (VBA) in patients was much greater than that of the healthy volunteers (P < 0.01). After treatment, rotational blood flow velocity reduction percentage of VBA in each treatment group was much lower than that of each group before treatment. EECP + traction group experienced the greatest decrease of rotational blood flow velocity reduction percentage of VBA, while EECP group experienced second greatest. CONCLUSION EECP and traction therapy can relieve the symptoms of rotational VBI, improve the rotational reduction of vertebrobasilar blood flow, and reduce the increased arterial impedance.
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Alexandrov AWW. Hyperacute ischemic stroke management: reperfusion and evolving therapies. Crit Care Nurs Clin North Am 2010; 21:451-70. [PMID: 19951763 DOI: 10.1016/j.ccell.2009.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Management of acute ischemic stroke patients is organized around several priorities aimed at ensuring optimal patient outcomes, the first of which is reperfusion therapy, followed by determination of pathogenic mechanism by provision of a comprehensive workup to determine probable cause of the ischemic stroke or transient ischemic attack, for the purpose of providing appropriate prophylaxis for subsequent events. Provision of secondary prevention measures along with therapies that prevent complications associated with neurologic disability, and evaluation for the most appropriate level of rehabilitation services are the final priorities during acute hospitalization. This article provides an overview of reperfusion therapies and emerging hemodynamic treatments for hyperacute ischemic strokes. Gaps in the scientific evidence that are driving current blood flow augmentation research are identified.
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Affiliation(s)
- Anne W Wojner Alexandrov
- Acute & Critical Care, School of Nursing, Comprehensive Stroke Center, University of Alabama, Birmingham 35249, USA.
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Marthol H, Brown CM, Zikeli U, Ziegler D, Dimitrov N, Baltadzhieva R, Hilz MJ. Altered cerebral regulation in type 2 diabetic patients with cardiac autonomic neuropathy. Diabetologia 2006; 49:2481-7. [PMID: 16955212 DOI: 10.1007/s00125-006-0368-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2006] [Accepted: 05/24/2006] [Indexed: 10/24/2022]
Abstract
AIMS/HYPOTHESIS Assessment of cerebral regulation in diabetic patients is often problematic because of the presence of cardiac autonomic neuropathy. We evaluated the technique of oscillatory neck suction at 0.1 Hz to quantify cerebral regulation in diabetic patients and healthy control subjects. SUBJECTS AND METHODS In nine type 2 diabetic patients with cardiac autonomic neuropathy and 11 age-matched controls, we measured blood pressure and cerebral blood flow velocity responses to application of 0.1 Hz neck suction. We determined spectral powers and calculated the transfer function gain and phase shift between 0.1 Hz blood pressure and cerebral blood flow velocity oscillations as parameters of cerebral regulation. RESULTS In the patients and control subjects, neck suction did not significantly influence mean values of the RR interval, blood pressure and cerebral blood flow velocity. The powers of 0.1 Hz blood pressure and cerebral blood flow velocity oscillations increased in the control subjects, but remained stable in the patients. Transfer function gain remained stable in both groups. Phase shift decreased in the patients, but remained stable in control subjects. CONCLUSIONS/INTERPRETATION The absence of an increase in the power of 0.1 Hz blood pressure and cerebral blood flow velocity oscillations confirmed autonomic neuropathy in the diabetic patients. Gain analysis did not show altered cerebral regulation. The decrease in phase shift in the patients indicates a more passive transmission of neck suction-induced blood pressure fluctuations onto the cerebrovascular circulation, i.e. altered cerebral regulation, in the patients, and is therefore suited to identifying subtle impairment of cerebral regulation in these patients.
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Affiliation(s)
- H Marthol
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
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