Intracranial pressure reduction by a central alpha-2 adrenoreceptor agonist after subarachnoid hemorrhage

Role of Dexmedetomidine in Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Scoping Review

Dexmedetomidine (DEX), an α2-adrenergic agonist, has been widely used for anesthesia, pain control, and intensive care unit sedation. Besides sleep-like sedation, DEX has many other beneficial effects, such as anti-inflammation, antioxidation, and anticell death. Subarachnoid hemorrhage (SAH), a severe and potentially fatal form of stroke, is a complex disease that is divided into 2 phases: early brain injury and delayed cerebral ischemia. In each phase, several pathologic changes are involved, including disturbed intracranial homeostasis, metabolic failure, blood-brain barrier damage, vasospasm, microthrombosis, and cortical spreading depolarization. DEX has been shown to have an effect on these SAH-related pathologic processes. Research shows that DEX could serve as a protective therapy for patients with SAH due to its ability to maintain stable intracerebral homeostasis, balance coagulation-fibrinolysis, repair a damaged blood-brain barrier as well as prevent vasospasm and suppress cortical spreading depolarization by anti-inflammatory, antioxidative, antiapoptotic, and vasoconstriction-dilation effects. In this scoping review, we critically assess the existing data on the potential protective effect of DEX after SAH. So far, only 1 retrospective clinical trial assessing the effect of DEX on clinical outcomes after SAH has been performed. Hence, more trials are still needed as well as translational research bringing results from bench to bedside.

The effect of xylazine on intracranial pressure in anesthetized and standing horses

OBJECTIVE

To determine the effect of xylazine on intracranial pressure (ICP) in standing compared to isoflurane-anesthetized horses.

DESIGN

Prospective, crossover study design.

SETTING

University Teaching Hospital.

ANIMALS

Six adult horses donated to the University. Horses were determined to be healthy via physical examination, complete blood count, and neurological evaluation.

INTERVENTIONS

Horses were anesthetized, maintained on isoflurane in oxygen in left lateral recumbency, and ventilated to normocapnia. Horses were instrumented for intraparenchymal measurement of ICP, invasive blood pressure, pulse oximetry, and end tidal gas analyzer. Xylazine 1 mg/kg was administered IV and ICP, systolic arterial pressure, mean arterial pressure (MAP), diastolic arterial pressure, and heart rate were recorded and cerebral perfusion pressure (CPP) was calculated for the following 15 minutes. Twenty-four to 36 hours following anesthetic recovery, xylazine 1 mg/kg was administered IV and ICP, heart rate, and Doppler blood pressure (BPdop) on the tail were monitored for 15 minutes.

MEASUREMENTS AND MAIN RESULTS

There was a decrease in ICP following administration of xylazine in anesthetized horses (P < 0.003) but not standing horses (P = 0.227). There was an increase in systolic arterial pressure, MAP, diastolic arterial pressure (P < 0.001), and BPdop (P = 0.001) following administration of xylazine. As a result, CPP increased in anesthetized horses (P < 0.03). There was a negative association between ICP and MAP in anesthetized horses (P = 0.007) but not ICP and BPdop conscious horses (P = 0.379).

CONCLUSIONS

Administration of xylazine to anesthetized horses resulted in an increased CPP due to decreased ICP with concurrent increased MAP. Administration of xylazine to standing horses did not result in a change in ICP. However, with the increase in BPdop found in awake horses, it is likely that CPP would also increase in awake horses following xylazine administration.

Gene expression-based comparison of the human secretory neuroepithelia of the brain choroid plexus and the ocular ciliary body: potential implications for glaucoma

Background

The neuroepithelia of the choroid plexus (CP) in the brain and the ciliary body (CB) of the eye have common embryological origins and share similar micro-structure and functions. The CP epithelium (CPE) and the non-pigmented epithelium (NPE) of the CB produce the cerebrospinal fluid (CSF) and the aqueous humor (AH) respectively. Production and outflow of the CSF determine the intracranial pressure (ICP); production and outflow of the AH determine the intraocular pressure (IOP). Together, the IOP and ICP determine the translaminar pressure on the optic disc which may be involved in the pathophysiology of primary open angle glaucoma (POAG). The aim of this study was to compare the molecular machinery of the secretory neuroepithelia of the CP and CB (CPE versus NPE) and to determine their potential role in POAG.

Methods

We compared the transcriptomes and functional annotations of healthy human CPE and NPE. Microarray and bioinformatic studies were performed using an Agilent platform and the Ingenuity Knowledge Database (IPA).

Results

Based on gene expression profiles, we found many similar functions for the CPE and NPE including molecular transport, neurological disease processes, and immunological functions. With commonly-used selection criteria (fold-change > 2.5, p-value < 0.05), 14% of the genes were expressed significantly differently between CPE and NPE. When we used stricter selection criteria (fold-change > 5, p-value < 0.001), still 4.5% of the genes were expressed differently, which yielded specific functions for the CPE (ciliary movement and angiogenesis/hematopoiesis) and for the NPE (neurodevelopmental properties). Apart from a few exceptions (e.g. SLC12A2, SLC4A4, SLC4A10, KCNA5, and SCN4B), all ion transport protein coding genes involved in CSF and AH production had similar expression profiles in CPE and NPE. Three POAG disease genes were expressed significantly higher in the CPE than the NPE, namely CDH1, CDKN2B and SIX1.

Conclusions

The transcriptomes of the CPE and NPE were less similar than we previously anticipated. High expression of CSF/AH production genes and candidate POAG disease genes in the CPE and NPE suggest that both might be involved in POAG.

Dexmedetomidine for neurological surgery

Dexmedetomidine is a new intravenous drug gaining popularity in neuroanesthesia and neurocritical care practice. This alpha2-adrenergic receptor agonist offers a unique "cooperative sedation," anxiolysis, and analgesia with no respiratory depression. Cerebral effects are generally consistent with a desirable neurophysiological profile, including neuroprotective characteristics. In addition, sympatholytic and antinociceptive properties allow for hemodynamic stability at critical moments of neurosurgical stimulation. This review will address the neuropharmacology and neurophysiology of alpha2-adrenergic agonists and will specifically consider the rapidly evolving applicability of dexmedetomidine as an adjuvant to neurosurgical case management.

The role of autacoids and the autonomic nervous system in cardiovascular responses to radio-frequency energy heating

Among the potential effects of exposure to high levels of radio-frequency energy (RFE) (which includes microwaves), an increase in body temperature is the primary consequence. Release of autacoids and activity of the autonomic nervous system may influence (or be directly responsible for) some of the physiological changes that occur in conjunction with this hyperthermia. The main focus of this review is the interaction of autacoids and the autonomic nervous system with cardiovascular changes during heating. Differences between environmental and RFE-induced heating (such as rate of temperature change and degree of skin vs. core heating) may be important when considering these effects. Antihistamines exhibited no beneficial effect on circulatory collapse during RFE-induced heating. The serotonergic blocker methysergide decreased survival time in rats during terminal RFE exposure, despite no effects on heart rate (HR) or blood pressure. Although blockade of platelet-activating factor resulted in lower HR before RFE exposure, there was a lack of effect on the subsequent increase in HR during heating. Nitric oxide did not contribute to the hypotension that occurs due to rapid heating by RFE exposure. There have been either no or very limited studies of effects of prostaglandins, bradykinin, or angiotensin on RFE-induced heating responses. beta-Adrenoceptor antagonism with propranolol resulted in significantly decreased survival times and lower final colonic temperatures during RFE exposure. A lack of effects of nadolol on survival time and temperature, coupled with its poor ability to traverse the blood-brain barrier, suggests that central beta-adrenergic stimulation rather than peripheral stimulation may alter thermoregulation. Effects of the autonomic nervous system (as studied by adrenoceptor blockade) on potassium changes during heating have not been fully investigated. Such changes could be important in animals' responses to RFE and other modalities of heating, and should be studied in future.

In vivo study of liposomes as drug carriers to oral mucosa using EPR oximetry

The purpose of this study was to select the best types of liposomes for use as drug carriers for topical treatment of oral mucosal lesions. Electron paramagnetic resonance (EPR) oximetry, using the paramagnetic probe lithium phthalocyanine, was used in vivo to measure the effects of a hyperemic drug, benzyl nicotinate (BN) which was incorporated into liposomes of varying size and composition. The liposomes were made from either hydrogenated or non-hydrogenated soy lecithin and mixed with polymethyl methacrylate ointment for application. EPR oximetry was used to measure the partial pressure of oxygen (pO2) in the oral mucosa before and after application of liposomes. It was found that the most pronounced changes of pO2 in oral mucosa and also the longest action of the drug occurred after the topical application of BN in multi-lamellar liposomes made from hydrogenated soy lecithin (p<0.0001). When these liposomes were applied to oral mucosa over 3 successive days it was found that pO2 increased the most on the first day, the effect gradually decreased following application on the second and third days. The duration of the resulting hyperemia was the longest on the second day (p<0.01). Among the examined carriers, multi-lamellar liposomes made from hydrogenated soy lecithin appear to be the most appropriate for local drug delivery to oral mucosa.

Effects of milrinone on jugular bulb oxygen saturation and cerebrovascular carbon dioxide reactivity in patients undergoing coronary artery bypass graft surgery

BACKGROUND

Jugular bulb oxygen saturation (Sjv(o(2))) is a surrogate marker for global cerebral oxygenation. The effect of milrinone on Sjv(o(2)) and the cerebrovascular carbon dioxide reactivity (CCO2R) was investigated.

METHODS

Thirty patients scheduled for coronary artery bypass graft surgery (CABG) were studied prospectively. After sternotomy, normoventilation (at T(1); Pa(co(2))=4.7-5.0 kPa) and hyperventilation (at T(2); Pa(co(2))=3.3-3.7 kPa) were induced and the changes in Sjv(o(2)) (DeltaSjv(o(2))) and Pa(co(2)) (DeltaPa(co(2))), and DeltaSjv(o(2))/DeltaPa(co(2)) (CCO(2)R) were measured. After normoventilation was re-established (at T(3)), milrinone 50 microg kg(-1) was given (at T(4)), followed by hyperventilation (at T(5)), and DeltaSjv(o(2)), DeltaPa(co(2)) and CCO(2)R were measured.

RESULTS

After milrinone administration at normoventilation (T(3) and T(4)), cardiac index and mixed venous oxygen saturation increased, while mean arterial pressure and systemic vascular resistance index decreased, without a significant change in Sjv(o(2)). Before milrinone administration (T(1) and T(2)), hyperventilation decreased Pa(co(2)) and Sjv(o(2)), and DeltaSjv(o(2)) showed positive linear correlation with DeltaPa(co(2)). After milrinone administration (T(4) and T(5)), hyperventilation decreased Pa(co(2)) and Sjv(o(2)), and DeltaSjv(o(2)) showed positive linear correlation with DeltaPa(co(2)). There was no significant difference in CCO(2)R before and after milrinone administration (13.3 (5.7)% kPa(-1) and 12.3 (3.9)% kPa(-1), respectively).

CONCLUSIONS

Although milrinone induced significant haemodynamic changes, Sjv(o(2)) and CCO(2)R were unchanged during its administration.

Effect of Propofol and Clonidine on Cerebral Blood Flow Velocity and Carbon Dioxide Reactivity in the Middle Cerebral Artery

This study was designed to evaluate the effects of propofol alone and propofol-clonidine combination on human middle cerebral artery blood flow velocity (Vmca) and cerebrovascular carbon dioxide (CO2) response by using transcranial Doppler ultrasonography. Mean Vmca in response to changes in arterial partial pressure of CO2 (Paco2) was determined under the following conditions: awake (group 1), propofol anesthesia (group 2), and combined propofol-clonidine anesthesia (group 3). Normocapnic, hypercapnic, and hypocapnic values of heart rate, mean arterial pressure, partial end-tidal CO2 pressure, Paco2, and Vmca were obtained. The mean Vmca in groups 2 and 3 was significantly lower than that in group 1 at each level of Paco2. The calculated Vmca at each level of Paco2 was not different between groups 2 and 3. There was a correlation between Paco2 and Vmca in all groups, but in the anesthetized groups the effect of Paco2 on Vmca was attenuated. The present data demonstrated that clonidine-propofol does not change CO2 reactivity compared with propofol alone, but both anesthetics attenuate cerebral blood flow compared with awake controls.

Attenuation of cerebral vasospasm in rabbits using clonidine hydrochloride, a central adrenergic agonist

The aim of this study was to assess, firstly, if exclusion of central noradrenergic areas in the hypothalamus and brain stem with the central sympathetic blocker clonidine hydrochloride could prevent the development of chronic vasospasm following experimental subarachnoid haemorrhage in rabbits and, secondly, if, parallel with the effect on cerebral arteries, changes in dopamine beta-hydroxylase concentration in the hypothalamus and brain stem could also be detected. Experimental subarachnoid haemorrhage, in concentrations of 1 ml of autologous arterial blood/1 kg of body weight was carried out on 18 New Zealand rabbits. Histological specimens were obtained by the method of perfusion fixation after the rabbits were sacrificed on day 8 after subarachnoid haemorrhage. The spastic effect of experimentally induced subarachnoid haemorrhage was determined by assessing the intensity of corrugation of the intima of the rabbit basilar artery by the previously developed method of corrugation coefficient and computer image analysis. The concentration and localization of dopamine beta-hydroxylase in noradrenaline-containing neurons was immunohistochemically assessed (semiquantitatively as 0, 1 and 2) with anti-dopamine beta-hydroxylase, at precisely defined sites of the hypothalamus and brain stem of the same rabbit. The results revealed less corrugated and smoother intima in the basilar artery and significantly lower dopamine beta-hydroxylase concentration in the control group of rabbits with sham subarachnoid haemorrhage and without any additional interventions (mean corrugation coefficient=1.123+/-0.024, P=0.35 x 10(-3); mean dopamine beta-hydroxylase=0.350+/-0.071, P=0.22 x 10(-3)), and smoother intima in the basilar artery with significantly lower concentration of dopamine beta-hydroxylase in the clonidine group (rabbits with subarachnoid haemorrhage and central alpha(2)-blocker clonidine hydrochloride at a daily dose of 0.03 mg/kg of body weight for 8 days; mean corrugation coefficient=1.177+/-0.058, P=1.7 x 10(-3); mean dopamine beta-hydroxylase=0.583+/-0.175, P=1.1 x 10(-3)). In comparison, the haemorrhage only group (rabbits with subarachnoid haemorrhage and without medication; mean corrugation coefficient=1.370+/-0.101; mean dopamine beta-hydroxylase=1.214+/-0.313) displayed intensive corrugation of the intima of the basilar artery and a significantly more intensive accumulation of dopamine beta-hydroxylase than did the control group and the clonidine group. The results of this study demonstrated that the central alpha(2)-blocker clonidine hydrochloride effectively prevents vasospasm, and diminishes the concentration of cerebral dopamine beta-hydroxylase in the hypothalamus and brain stem after experimental subarachnoid haemorrhage in rabbits.

The effects of ketamine-xylazine anesthesia on cerebral blood flow and oxygenation observed using nuclear magnetic resonance perfusion imaging and electron paramagnetic resonance oximetry

Ketamine-xylazine is a commonly used anesthetic for laboratory rats. Previous results showed that rats anesthetized with ketamine-xylazine can have a much lower cerebral partial pressure of oxygen (P(t)O(2)), compared to unanesthetized and isoflurane anesthetized rats. The underlying mechanisms for the P(t)O(2) reduction need to be elucidated. In this study, we measured regional cerebral blood flow (CBF) using nuclear magnetic resonance (NMR) perfusion imaging and cortical P(t)O(2) using electron paramagnetic resonance (EPR) oximetry in the forebrain of rats under isoflurane, ketamine, ketamine-xylazine and isoflurane-xylazine anesthesia. The results show that in ventilated rats ketamine at a dose of 50 mg/kg does not induce significant changes in CBF, compared to isoflurane. Ketamine-xylazine in combination causes 25-65% reductions in forebrain CBF in a region-dependent manner. Adding xylazine to isoflurane anesthesia results in similar regional reductions in CBF. EPR oximetry measurements show ketamine increases cortical P(t)O(2) while xylazine decreases cortical P(t)O(2). The xylazine induced reduction in CBF could explain the reduced brain oxygenation observed in ketamine-xylazine anesthetized rats.

Changes in cerebral hemodynamics after a single dose of clonidine in severely head-injured patients

alpha 2-Adrenergic agonists induce cerebral vasoconstriction, reduce intracranial pressure (ICP) in experimental animals and may be useful in the hemodynamic management of head-injured patients. We studied the effects of the alpha 2 agonist clonidine on the cerebral circulation in 12 head-injured patients (Glasgow Coma Scale score < 8). Middle cerebral artery flow velocity (MCAV), ICP, mean arterial pressure (MAP), and cerebral perfusion pressure (CPP), were continuously recorded before (T0), at the end (T1), and 30 min after (T2) a 10-min intravenous (i.v.) infusion of 2.5 micrograms/kg clonidine. The cerebral arteriovenous oxygen content difference (AVDO2) and Paco2 were sequentially obtained. ICP, Paco2, AVDO2, and MCAV did not change after clonidine administration. In contrast, MAP and CPP decreased (P < 0.05 and P < 0.05, respectively, at T1 and T2). Three subjects displayed a transient increase in ICP (> 10 mm Hg) at T1; this increase was concomitant with the decrease in MAP. Clonidine administered as an i.v. infusion may induce a critical but transient increase in ICP in some severely head-injured patients. This effect may result from cerebral autoregulatory vasodilation and increased cerebral blood volume as a response to the hypotensive effects of clonidine.