The Change in Regional Cerebral Oxygen Saturation after Stellate Ganglion Block

The Change in Regional Cerebral Oxygen Saturation after Stellate Ganglion Block: "Korean J Pain. Jun 2010; 23(2): 142–146.
Published online May 31, 2010.



Background

Stellate ganglion block (SGB) is known to increase blood flow to the innervations area of the stellate ganglion. Near infrared spectroscopy reflects an increased blood volume and allows continuous, non-invasive, and bedside monitoring of regional cerebral oxygen saturation (rSO2). We investigated the influence of SGB on bilateral cerebral oxygenation using a near infrared spectroscopy.



Methods

SGB was performed on 30 patients with 1% lidocaine 10 ml using a paratracheal technique at the C6 level and confirmed by the presence of Horner's syndrome. The blood pressure (BP), heart rate (HR) and rSO2 were measured before SGB and 5, 10, 15 and 20 minutes after SGB. Tympanic temperature of each ear was measured prior to SGB and 20 minutes after SGB.



Results

The increments of the rSO2 on the block side from the baseline were statistically significant at 5, 10, 15 and 20 minutes. The rSO2 on the non-block side compared with the baseline, however, decreased at 15 and 20 minutes. The difference between the block and the non-block sides was significant at 15 and 20 minutes. The BP at 10, 15 and 20 minutes was increased and the HR was increased at 10 and 15 minutes.



Conclusions

We observed an increment of the rSO2 on the block side from the baseline; however, the rSO2 on the non-block side decreased."

Local distribution of the effects of sympathetic stimulation on cerebral blood flow in the rat

Local distribution of the effects of sympathetic s... [Brain Res. 1990] - PubMed - NCBI: "Although the density of sympathetic fibres on the cerebral vessels varies regionally, the cerebral circulatory effects of electrical stimulation of these fibres on the cerebral circulation have not been mapped in detail. In the present study the effects of sympathetic stimulation on local cerebral blood flow were examined in urethane anaesthetized rats using autoradiographic techniques. Initial experiments determined that unilateral stimulation of the superior cervical ganglion altered cerebral circulatory dynamics to an extent sufficient to reduce cerebral venous pressure by 1.1 +/- 0.2 mm Hg. Local cerebral blood flow was measured with iodo[14C]antipyrine autoradiography in 4 groups: (1) sham; (2) sham + unilateral sympathetic nerve section; (3) unilateral stimulation of the superior cervical ganglion; and (4) unilateral sympathetic stimulation + contralateral sympathetic nerve section. In the sham animals, local cerebral blood flow was equivalent in the innervated and denervated hemispheres. During stimulation plus contralateral nerve section, a regionally heterogeneous response to sympathetic stimulation was observed. Local cerebral blood flow was reduced 11-19% on the stimulated side in over one half (15/28) of the regions examined (e.g. thalamic nuclei and caudate nucleus). In general, ipsilateral reductions in flow occurred in the territory supplied by the middle cerebral, posterior cerebral and posterior communicating arteries and their branches. Cerebral blood flow was symmetrical in regions supplied by the basilar and anterior cerebral arteries and in some midline structures."

Effects of stellate ganglion block on cerebral haemodynamics as assessed by transcranial Doppler ultrasonography

Background. Stellate ganglion block (SGB) causes vasodilatation in the skin of the head and neck

because of regional sympathetic block. Its effects on cerebral haemodynamics, in health or in

disease, are not clear. We evaluated the effects of SGB on ipsilateral middle cerebral artery flow

velocity (MCAFV), estimated cerebral perfusion pressure (eCPP), zero flow pressure (ZFP),

carbon dioxide reactivity (CO2R) and cerebral autoregulation using transcranial Doppler

ultrasonography (TCD).



Methods. Twenty male patients, with pre-existing brachial plexus injury, and undergoing SGB for

the treatment of complex regional pain syndrome of the upper limb, were studied. For SGB, 10 ml

of plain lidocaine 2% was used and the onset of block was confirmed by presence of ipsilateral

Horner’s syndrome. The MCAFV, eCPP, ZFP, CO2R, and cerebral autoregulation were assessed

before and after SGB using established TCD methods. The changes in these variables were

analysed using Wilcoxon’s signed rank test.



Results. The block caused a significant decrease in MCAFV from median (inter-quartile range)

value of 61 (53, 67) to 55 (46, 60) cm s 1, a significant increase in eCPP from 59 (51, 67) to

70 (60, 78) mm Hg, and a significant decrease in ZFP from 32 (26, 39) to 25 (16, 30) mm Hg. There

were no significant changes in CO2R or cerebral autoregulation.

http://bja.oxfordjournals.org/content/95/5/669.full.pdf

NE is critical for the acquisition of spatial working memory

The adrenergic system (utilizing norepinephrine, NE, as a neurotransmitter) is implicated in hippocampus-based learning and memory, in addition to its well known peripheral actions mediated by the sympathetic nervous system.

Using a more standard variation of the above protocol on the radial arm maze, we used this apparatus to test the role of NE in spatial working memory. We found significant, robust differences between Dbh-/- and Dbh+/- mice after a training period of approximately 14 days. To test whether this difference was due to a potential deficit in acquisition or performance, we restored NE in Dbh-/- mice by administering the synthetic precursor L-DOPS after four days of stable behavioral differences between genotypes. In a separate trial, we also restored NE signaling with dexmedetomidine, a selective alpha-2 receptor agonist. A gradual improvement by Dbh-/- mice to levels comparable to Dbh+/- mice indicated that NE is critical for the acquisition of spatial working memory, and suggested a role for the alpha-2 adrenergic receptor in the processing of spatial working memory.

Suggested Citation

Gertner, Michael J. and Thomas, Steven A., "The role of norepinephrine in spatial reference and spatial working memory" 08 June 2006. CUREJ: College Undergraduate Research Electronic Journal, University of Pennsylvania, http://repository.upenn.edu/curej/18.

Date Posted: 08 June 2006

This document has been peer reviewed.

Michael J. Gertner, University of Pennsylvania
Steven A. Thomas, University of Pennsylvania
http://repository.upenn.edu/curej/18/

Inflammation in dorsal root ganglia after peripheral nerve injury: Effects of the sympathetic innervation

Following a peripheral nerve injury, a sterile inflammation develops in sympathetic and dorsal root ganglia (DRGs) with axons that project in the damaged nerve trunk. Macrophages and T-lymphocytes invade these gan- glia where they are believed to release cytokines that lead to hyperexcitability and ectopic discharge, possibly contributing to neuropathic pain. Here, we examined the role of the sympathetic innervation in the inflammation of L5 DRGs of Wistar rats following transection of the sciatic nerve, comparing the effects of specific surgical in- terventions 10–14 days prior to the nerve lesion with those of chronic administration of adrenoceptor antago- nists. Immunohistochemistry was used to define the invading immune cell populations 7 days after sciatic transection. Removal of sympathetic activity in the hind limb by transecting the preganglionic input to the rele- vant lumbar sympathetic ganglia (ipsi- or bilateral decentralization) or by ipsilateral removal of these ganglia with degeneration of postganglionic axons (denervation), caused less DRG inflammation than occurred after a sham sympathectomy. By contrast, denervation of the lymph node draining the lesion site potentiated T-cell in- flux. Systemic treatment with antagonists of α1-adrenoceptors (prazosin) or β-adrenoceptors (propranolol) led to opposite but unexpected effects on infiltration of DRGs after sciatic transection. Prazosin potentiated the influx of macrophages and CD4+ T-lymphocytes whereas propranolol tended to reduce immune cell invasion. These data are hard to reconcile with many in vitro studies in which catecholamines acting mainly via β2-adrenoceptors have inhibited the activation and proliferation of immune cells following an inflamma- tory challenge. 

Autonomic Neuroscience: Basic and Clinical 182 (2014) 108–117 

Neuroscience Research Australia, Randwick, NSW 2031, and the University of New South Wales, Sydney, NSW 2052, Australia 

electric stimulation of the sympathetic cord in the upper thoracic level on the middle cerebral artery blood flow velocity

The effect of electric stimulation of the sympathetic cord in the upper thoracic level on the middle cerebral artery blood flow velocity (V(MCA)) in humans was examined using transcranial Doppler sonography monitoring during surgery for palmar hyperhidrosis. Sympathetic stimulation resulted in marked and rapid increases Of V(MCA). The responses were preceded by prompt increases of mean arterial blood pressure (MABP) and heart rate (HR). Division of the sympathetic cord cranially or caudally to the stimulation site partially reduced the V(MCA), MABP and HR responses. Both these operations reduced sympathetic pathways to the heart as reflected by a decrease in HR and MABP. The integrity of the sympathetic pathway from the stimulation site through the superior cervical ganglion and the carotid plexus was not a prerequisite for a V(MCA) response. Our data suggest that the V(MCA) increase mainly results from stimulation of the heart and the cardiovascular system, resulting in marked increases of blood pressure and heart rate.

CEREBROVASCULAR DISEASES Volume: 2 Issue: 6 Pages: 359-364 Published: NOV-DEC 1992

Treatment of social phobia by endoscopic thoracic sympathicotomy

Eur J Surg Suppl. 1998;(580):27-32.

Treatment of social phobia by endoscopic thoracic sympathicotomy.

Telaranta T.

THE PATHOGNOMONIC SYMPTOMS OF SOCIAL PHOBIA: HYPERHIDROSIS, PALPITATION, BLUSHING, TREMOR, AND ANXIETY, WERE ALL HIGHLY SIGNIFICANTLY (P < 0.001) ALLEVIATED BY ETS. 88% OF THE PATIENTS WERE SATISFIED WITH THE RESULT. THERE WERE NO COMPLICATIONS.

CONCLUSION:

ETS seems a promising alternative to conservative therapy for social phobia.

Can J Anaesth. 2002 Aug-Sep;49(7):758-9.

Unexpected beneficial effect of stellate ganglion block in a schizophrenic patient.

Takano M, Takano Y, Sato I.

http://www.ncbi.nlm.nih.gov/pubmed/12193502

Jpn J Ophthalmol. 2006 Nov-Dec;50(6):567-9.

Visual hallucinations following stellate ganglion block in a patient with central retinal artery occlusion.

Kurimoto T, Takata M, Nishimura M, Tagami Y, Okamoto N, Mimura O.

http://www.ncbi.nlm.nih.gov/pubmed/17180540

Masui. 1993 Nov;42(11):1696-8.

[Three case reports of the use of stellate ganglion block for the climacteric psychosis].

Ikeda K1, Isshiki A, Yoshimatsu N, Oumi A, Ito S, Ikeda T.

Author information

Abstract

There are many reports of the use of stellate ganglion block (SGB) for the climacteric psychosis, which is considered to be sympathicotonic response to stress. We experienced three cases of the SGB therapy for the climacteric psychosis. We performed SGB three times per week by 1% lidocaine 5 ml, and observed improvements of the symptoms after doing SGB for five times. The patients reported psychological relaxation after receiving SGB therapy. We examined the changes of the serum concentrations of ACTH, LH, FSH, and catecholamines (epinephrine, norepinephrine) before and after SGB in 8 patients who were suffering from climacteric psychosis, because we wanted to know the endocrinological response to SGB. We observed a significant decrease in norepinephrine concentration after SGB, which is reasonable considering the sympathetic blockage. There were no significant changes of ACTH, LH, FSH, and epinephrine. We conclude that SGB therapy must be effective for the climacteric psychosis because of sympathetic blockade. But we could not clarify the influence of endocrinological response to SGB.

"lowering of heart rate and blood pressure, decreased responsiveness of the cardiocirculatory system to emotional stimuli after sympathectomy

"lowering of heart rate and blood pressure, decreased responsiveness of the cardiocirculatory system to emotional stimuli: it is an effect that is especially noticeable in patients operated on for erythrophobia and less evident in those operated for hyperhidrosis. It is almost always a welcome phenomenon, which contributes considerably to the feeling of tranquility and serenity that generally supersedes anxiety. Excessive reduction in blood pressure or heart rate may lead to a state of weakness and fatigue that may require removal of the clips in approx. 2%. This rare state of asthenia contrasts with the increased energy and vigor that most patients experience when they feel freed from overwhelming anxiety."    

"The neurovegetative nervous system is, however, very dynamic and tends to adapt continuously during lifetime to all environmental or organic changes and conditions. Therefore, it reacts very individually when a reflex circuit has been blocked. The resulting side effects cannot be predicted in detail, and though they in most patients are relatively mild or even absent, there is a small group of patients developing heavy side effects. Therefore, surgery should only be considered in carefully selected cases in whom non-invasive treatment has failed and in whom the detrimental consequences of erythrophobia regarding the psychosocial situation and the quality of life is such to justify more adverse side effects. It should also always be kept in mind that therapy can be ineffective and that, in the long term, 10-15% of patients do not consider themselves satisfied with the result of surgery. In any case, the author prefers the use of a potentially reversible surgical technique (ESB), instead of destructive techniques (cutting, coagulation, removal of ganglia)."  

http://www.chir.it/en_erythrophobia.php

significant associations between heart rate and regional cerebral blood flow

Neurosci Biobehav Rev. 2012 Feb;36(2):747-56. doi: 10.1016/j.neubiorev.2011.11.009. Epub 2011 Dec 8.

A meta-analysis of heart rate variability and neuroimaging studies: implications for heart rate variability as a marker of stress and health.

The intimate connection between the brain and the heart was enunciated by Claude Bernard over 150 years ago. In our neurovisceral integration model we have tried to build on this pioneering work. In the present paper we further elaborate our model and update it with recent results. Specifically, we performed a meta-analysis of recent neuroimaging studies on the relationship between heart rate variability and regional cerebral blood flow. We identified a number of regions, including the amygdala and ventromedial prefrontal cortex, in which significant associations across studies were found. We further propose that the default response to uncertainty is the threat response and may be related to the well known negativity bias. Heart rate variability may provide an index of how strongly 'top-down' appraisals, mediated by cortical-subcortical pathways, shape brainstem activity and autonomic responses in the body. If the default response to uncertainty is the threat response, as we propose here, contextual information represented in 'appraisal' systems may be necessary to overcome this bias during daily life. Thus, HRV may serve as a proxy for 'vertical integration' of the brain mechanisms that guide flexible control over behavior with peripheral physiology, and as such provides an important window into understanding stress and health.

http://www.ncbi.nlm.nih.gov/pubmed/22178086

important relationship among cognitive performance, HRV, and prefrontal neural function

"These findings in total suggest an important relationship among cognitive performance, HRV, and prefrontal neural function that has important implications for both physical and mental health. Future studies are needed to determine exactly which executive functions are associated with individual differences in HRV in a wider range of situations and populations."

http://www.ncbi.nlm.nih.gov/pubmed/19424767

The sympathoadrenal system is one of the major pathways mediating physiological responses in the organism

The sympathoadrenal system is one of the major pathways mediating physiological responsesin the organism. The sympathoadrenal system plays an important role in the regulation of blood pressure, glucose, sodium and other key physiological and metabolic processes. In many disease states, the sympathoadrenal system is affected and by corrective physiological responses the sympathoadrenal system preserves homeostasis. Many therapeutic agents are either adrenergic activators or inhibitors. Therefore, measurements of the components of the sympathoadrenal system and the activity of the sympathoadrenal system have been of major interest for decades.

Levels of plasma (p-) noradrenaline (NA), the sympathetic neurotransmitter, have been used to indicate activity of the neuronal sympathoadrenal component, while adrenaline (Adr) levels indicate activity of the hormonal adrenomedullary component of the sympathoadrenal system (Christensen 1991, Goldstein 1995, Christensen & Norsk 2000).

Based upon the absence of an arterio-venous increase in p-DOPA concentration in sympathectomized limbs and a decrease in p-DOPA after inhibition of tyrosine hydroxylase (TH) in dogs, it was concluded that DOPA can pass across sympathetic neuronal membranes to reach the general circulation and furthermore, that p-DOPA may be related to regional rate of tyrosine hydroxylation (Goldstein et al 1987a). P-DOPA only demonstrated minimal changes during stimuli that produced significant changes in p-NA. Due to partly parallel changes of p-NA and p-DOPA, however, it was believed that p-DOPA reflect the rate of catecholamine synthesis and that p-DOPA was a simple and direct index of TH activity in vivo (Eisenhofer et al 1988, Goldstein & Eisenhofer 1988, Garty et al 1989b). It was inferred that p-DOPA levels may be an index of sympathetic activity.

Department of Internal Medicine and Endocrinology, Herlev University Hospital, Herlev.

Correspondence: Ebbe Eldrup, Bolbrovænge 29, DK-2960 Rungsted Kyst.

Official opponents: Jens H. Henriksen, professor, MD, and Jan Abrahamsen, MD.

Dan Med Bull 2004;51:34-62.

"Sympathectomy can enhance or suppress antibody production"

Neuropsychiatry - Google Books: Neuropsychiatry
 edited by Randolph B. Schiffer, Stephen M. Rao, Barry S. Fogel