Cerebral metabolic effects of glycerol infusion in diabetics with stroke

Measurement of cerebral blood flow and metabolism before and after intravenous infusion of 10% glycerol was investigated in 22 patients with acute cerebral ischemia, 10 of whom had diabetes mellitus and 12 of whom did not. In diabetic patients, resulting increases of hemispheric blood flow and reduction of oxygen consumption and CO₂ production were not significant whereas these changes in the non-diabetic group were significant. In diabetics cerebral glucose consumption and glucose:oxygen utilization ratio increased significantly but remained unchanged in non-diabetics. Following glycerol infusion, release of free fatty acids and inorganic phosphate from the infarcted hemisphere was diminished or reversed in both groups. It is postulated that the differences in cerebral metabolic responses to glycerol among an acute stroke population with diabetes compared to a similar group with acute stroke but without diabetes may be accounted for by the depressed cerebral glucose consumption in diabetics resulting from elevated blood levels of β-hydroxybutyrate, which tends to be reversed by the antiketogenic effect of glycerol and/or by the greater rise in blood glucose in diabetics following glycerol administration. Hence glycerol would not reduce cerebral oxygen consumption and CO₂ production in the diabetics as much as in the non-diabetics although the release of cerebral free fatty acids and inorganic phosphate from the infarcted brain would be reduced or reversed in both groups. It is concluded that intravenous glycerol infusion may improve uncoupled cerebral oxidative phosphorylation or provide the brain with an additional source of high energy phosphate bonds (ATP production) such as glycerol phosphate.     

Preservation of cerebral autoregulation in the unanesthetized hypoxemic newborn dog

Studies were conducted to determine the effects of hypoxemia on cerebral blood flow and the influence of hyperoxia and hypoxemia on autoregulation of cerebral blood flow in the unanesthetized newborn dog. Twenty-one newborn dogs less than 2 weeks of age were studied. Cerebral blood flow was measured using radioactive microspheres during successive periods of normotension, hypotension (produced by blood withdrawal) and normotension (produced by infusion of previously withdrawn blood). In the hyperoxic animals, arterial pO2 was maintained above 250 torr by having the animal breathe 100% oxygen, while in the hypoxemic animals arterial pO2 was maintained between 30 and 35 torr by having the animal breathe 12% O2. Cerebral blood flow increased significantly with hypoxemia. In both hypoxemic and hyperoxic animals cerebral blood flow was maintained constant in spite of a large fall in arterial blood pressure and cardiac output, demonstrating the presence of autoregulation. Calculated oxygen transport to the brain was constant during hypoxemia and hypotension in all animals. Thus autoregulation of cerebral blood flow is present in newborn animals and is preserved under conditions of moderate hypoxemia.     

Acute poisoning with triethyltin in the rat. Changes in cerebral blood flow, cerebral oxygen consumption, arterial and cerebral venous blood gases

Experiments were conducted with rats in two groups. In group 1 (survival group) triethyltin was administered i.p. once in a dose of 2.5 mg/kg body weight and in group 2 (terminal group) the animals received triethyltin in a dose of 9 mg/kg of body weight. Twelve and twenty-four hours after triethyltin injection a decrease of 30 to 40% in cerebral blood flow was observed in both groups. A decrease of systemic arterial blood pressure and changes in hematocrit value were found at that time. Progressive bradycardia was noted in all animals at all times of observation. Additionally, 48 h after intoxication, cerebral blood flow was increased in both groups by 13 to 24% above control values. The described changes were accompanied by macroscopic features of brain edema and changes in the cerebral vascular network. Cerebral oxygen consumption was augmented by about 18% 12 h after triethyltin injection in group 1. After 24 h it decreased by about 60% compared with control values, and after 48 h it returned to normal. In group 2 cerebral oxygen consumption was decreased significantly throughout the observation period. This reflects the state of cerebral metabolism at these stages of cerebral edema. The results underscore the necessity of simultaneous monitoring of cerebral blood flow and blood gases in order to distinguish between the particular stages of brain edema revealed by biochemical tests.     

Interstitial glycerol increase in microdialysis after glycerol enema.

Microdialysis allows the measurement of extracellular concentrations of various endogenous substances, such as excitotoxic amino acids or metabolic end products. Recent advances in microdialysis techniques have led to widespread use in patients with brain disorders. Microdialysis has proved to be a useful tool for monitoring cerebral biochemical metabolism and secondary brain damage in severe head injury, subarachnoid haemorrhage, stroke, and epilepsy. In our neurosurgical intensive care unit, microdialysis was performed on 42 patients. Four patients received a glycerol enema for therapy of a paralytic ileus. A glycerol peak was observed in both intracerebral and subcutaneous microdialysis occurring three to four hours after the glycerol enema in all four patients. The highest glycerol value was 1187micromol/l cerebral and 2997micromol/l in the subcutaneous tissue. Our study indicates that besides the measurement of serum osmolality and serum glycerol level, microdialysis may be an additional valuable tool to control glycerol therapy in patients with cerebral oedema and elevated intracranial pressure.     

Cerebral blood flow, metabolism and learning after a cerebral infarction in the rat (author's transl)

Experimental microembolization of the rat brain has been used as a model for the production of cerebral microinfarction which resulted in a decrease in blood flow and secondary brain edema with changes in the oxidative metabolic pathways. The use of radioactive microspheres as embolizing agents allowed to determine the number of microinfarctions and their localization. In every microinfarct, oedema developed and it could be quantified by measuring the water percentage as soon as the fourth hour following the microembolization. The activity of oxygen-dependent enzymes was severely reduced in the ischemic area around which hyperemia was present. A quick decrease in the ATP and glucose levels and an increase in the lactate levels were observed, showing that the energetic metabolism was deviated towards the anaerobic pathway. On the fifth day following the microembolization, the oedema disappeared. The cellular metabolic activity and the cerebral blood flow almost returned to normal values within the same time. The simultaneously study of an avoidance response in a conditioned learning test showed a correlation between the reappearance of this response and the regression of the oedema.     

Effects of glycerol on local cerebral glucose utilization and local cerebral blood flow of hypoxic rats

Effects of a continuous infusion of glycerol on the hypoxic rat were assessed by measurements of local cerebral glucose utilization and local cerebral blood flow using the quantitative autoradiographic 1-[C-14]-2-deoxyglucose and [C-14]-iodoantipyrine techniques, respectively. Local cerebral glucose utilization of the hypoxic rat was decreased in most of cerebral structures except for the amygdala, septal nucleus and the white matter. Local cerebral glucose utilization of the hypoxic rat treated with glycerol was recovered to the pattern of normal control, although glucose utilization of the nucleus raphe and locus ceruleus was accelerated. Cerebral blood flow of the hypoxic rat was elevated in almost of all measured structures. In particular, blood flow in the substantia nigra and locus ceruleus was increased significantly. The pattern of local cerebral blood flow of the hypoxic rat treated with glycerol was more analogous to that of normal control than of hypoxic rat without treatment. It is suggested that glycerol has beneficial effects by elevating local cerebral glucose utilization inhibited and decreasing local cerebral blood flow overshot on the hypoxic condition.     

Influence of various agents on the development of brain edema in the rat following microembolism. Protective effect of gamma-butyrolactone

Brain edema was induced in rats by injecting 50 mu microspheres, labelled with 85Sr, into the internal carotid artery. The use of radioactive microspheres as embolic agents enabled the number of microspheres to be determined in each cerebral hemisphere. Edema was assessed 12 or 24 h after embolization by measuring brain water content and, in some experiments, sodium and potassium. Pretreatments with dexamethasone, parachlorophenylalanine (an inhibitor of 5-hydroxytryptamine synthesis), mepyramine and metiamide (H1 and H2 histamine receptor antagonists) or aminophylline did not influence significantly the development of brain edema evaluated 24 h after embolization. Aminophylline treatment (100 mg/kg) markedly increased mortality following embolization. Gamma-butyrolactone (300 mg/kg, every 2 h) inhibited significantly the development of brain edema evaluated 12 hours after embolization. Increases in water and sodium in the embolized cerebral hemisphere were reduced by about 50%. This protective effect may be related to the known depressant action on brain metabolism.     

Unchanged cerebral blood flow and oxidative metabolism after acclimatization to high altitude.

The authors investigated the effect of acclimatization to high altitude on cerebral blood flow and oxidative metabolism at rest and during exercise. Nine healthy, native sea-level residents were studied 3 weeks after arrival at Chacaltaya, Bolivia (5,260 m) and after reacclimatization to sea level. Global cerebral blood flow at rest and during exercise on a bicycle ergometer was measured by the Kety-Schmidt technique. Cerebral metabolic rates of oxygen, glucose, and lactate were calculated by the Fick principle. Cerebral function was assessed by a computer-based measurement of reaction time. At high altitude at rest, arterial carbon dioxide tension, oxygen saturation, and oxygen tension were significantly reduced, and arterial oxygen content was increased because of an increase in hemoglobin concentration. Global cerebral blood flow was similar in the four conditions. Cerebral oxygen delivery and cerebral metabolic rates of oxygen and glucose also remained unchanged, whereas cerebral metabolic rates of lactate increased slightly but nonsignificantly at high altitude during exercise compared with high altitude at rest. Reaction time was unchanged. The data indicate that cerebral blood flow and oxidative metabolism are unaltered after high-altitude acclimatization from sea level, despite marked changes in breathing and other organ functions.     

Influence of early chronic phenobarbital treatment on cerebral arteriovenous differences of glucose and ketone bodies in the developing rat

The influence of an early chronic phenobarbital treatment on cerebral arteriovenous differences of glucose, lactate, pyruvate, beta-hydroxybutyrate and acetoacetate was studied in suckling rats. The animals were treated from day 2 to 21 after birth by a daily injection of 50 mg/kg phenobarbital or by saline and were studied at 10, 14 and 21 days. Phenobarbital treatment induced a decrease in cerebral arteriovenous difference of glucose at P14 and no change at P10 and P21. The barbiturate did not have any influence on cerebral arteriovenous difference of lactate and pyruvate at the three stages studied. Cerebral uptake of beta-hydroxybutyrate was unchanged at P10 and increased by two-fold at P14 and by threefold at P21 by phenobarbital. Cerebral arteriovenous difference of acetoacetate was low and did not change with the pharmacological treatment. At P14 and P21, the calculated amount of oxygen used by the brain for the oxidation of ketone bodies was twice as high in barbiturate- as in saline-treated rats and reached values of 47 and 16% respectively in phenobarbital-exposed animals. In addition, the barbiturate seemed to affect the carrier process of beta-hydroxybutyrate from blood to brain. The results of the present study are in good agreement with previous data from our laboratory showing that an early chronic phenobarbital treatment is able to induce a shift in the cerebral energy metabolism balance in favor of ketone bodies.     

The effect of glycerol and intracarotid phenoxybenzamine after experimental subarachnoid hemorrhage an ultrastructural study

Summary Twenty-four hours and one week, respectively, after subarachnoid hemorrhage (SAH) had been experimentally induced in baboons, therapeutic dosages of glycerol and/or phenoxybenzamine hydrochloride were injected intravenously. Groups of three animals were studied at various time intervals after SAH: one animal served as a control, one animal per group received phenoxybenzamine hydrochloride (PBZ), and thefinal animal received both PBZ and a 10% glycerol (in saline) injection. The animals were prepared for electron microscopy by whole body perfusion with a glutaraldehyde/phosphate fixative.Few ultrastructural abnormalities were noted in cerebral tissue in each of the animals receiving glycerol, whereas the brain tissue from the untreated animals and those which had been treated with PBZ alone showed morphological changes compatible with cerebral edema.This study was supported in part by U.S. Public Health Service Grant NS 00287.     

The role of SPECT brain imaging in assessing psychopathology in the medically ill.

Cerebral single photon emission computed tomography (SPECT), a method of functional brain imaging, measures cerebral blood flow and metabolism. This paper describes the imaging procedure and several cases where cerebral SPECT was of use in the differential diagnosis of medically ill patients who also presented with psychopathology. SPECT patterns in cerebrovascular disease, dementia, focal epilepsy, and AIDS are at present the best described and seem to be the most specific. Often changes in regional cerebral blood flow are seen before structural changes become apparent on CT or MRI. Cerebral SPECT can add valuable diagnostic information in assessing psychopathology in the medically ill and can often lead to changes in treatment.     

Pulsed arterial spin labeling effectively and dynamically observes changes in cerebral blood flow after mild traumatic brain injury

Cerebral blood flow is strongly associated with brain function, and is the main symptom and diagnostic basis for a variety of encephalopathies. However, changes in cerebral blood flow after mild traumatic brain injury remain poorly understood. This study sought to observe changes in cerebral blood flow in different regions after mild traumatic brain injury using pulsed arterial spin labeling. Our results demonstrate maximal cerebral blood flow in gray matter and minimal in the white matter of patients with mild traumatic brain injury. At the acute and subacute stages, cerebral blood flow was reduced in the occipital lobe, parietal lobe, central region, subcutaneous region, and frontal lobe. Cerebral blood flow was restored at the chronic stage. At the acute, subacute, and chronic stages, changes in cerebral blood flow were not apparent in the insula. Cerebral blood flow in the temporal lobe and limbic lobe diminished at the acute and subacute stages, but was restored at the chronic stage. These findings suggest that pulsed arterial spin labeling can precisely measure cerebral blood flow in various brain regions, and may play a reference role in evaluating a patient's condition and judging prognosis after traumatic brain injury.     

脑梗死急性期使用丁苯酞注射液对患者脑血流灌注和认知功能的影响

目的 研究伴有认知障碍的脑梗死急性期患者使用丁苯酞注射液对脑血流灌注和蒙特利尔认知 评估量表（Montreal cognitive assessment scale,MoCA）评分的影响。      

Use of 19F NMR spectroscopy for measurement of cerebral blood flow: a comparative study using microspheres

19F NMR was used to determine washout curves of an inert, diffusible gas (CHF3) from the cat brain. The cerebral blood flow was estimated from a bi- or tri-phasic fit to the deconvoluted wash-out curve, using the Kety-Schmidt approach. Cerebral blood flow values determined by 19F NMR show the expected responsiveness to alterations in Paco2, but are approximately 28% lower than cerebral blood flow values determined simultaneously by radioactive microsphere techniques. High concentrations of CHF3 have little effect on intracranial pressure, mean arterial blood pressure or Paco2, but cause small changes in the blood flow to certain regions of the brain. We conclude that 19F NMR techniques utilizing low concentrations of CHF3 have potential for the noninvasive measurement of cerebral blood flow.     

Evidence for a lactate pool in the rat brain that is not used as an energy supply under normoglycemic conditions.

Lactate derived from glucose can serve as an energy source in the brain. However, it is not certain how much lactate, directly taken from the blood circulation, may replace glucose as an energy source. This study aimed to estimate the uptake, release, and utilization of lactate entering the brain from the blood circulation. The change in cerebral venous-arterial glucose and lactate differences after lactate infusions in the anesthetized rat were measured. Ultrafiltration probes were placed in the aorta and in the jugular vein, and connected to a flow injection analysis system with biosensors for glucose and lactate. Measurements were taken every minute. Lactate efflux was observed at baseline, whereas an influx of lactate was seen during lactate infusion. Immediately after the infusion there was a net efflux of lactate from the brain. The results suggest that the majority of lactate moving into the brain is not used as an energy substrate, and that lactate does not replace glucose as an energy source. Instead, the authors propose the concept of a lactate pool in the brain that can be filled and emptied in accordance with the blood lactate concentration, but which is not used as an energy supply for cerebral metabolism.     

Cerebral blood flow and tissue metabolism in experimental cerebral ischemia of spontaneously hypertensive rats with hyper-, normo-, and hypoglycemia

The present study was designed to clarify the effect of blood glucose level on cerebral blood flow and metabolism during and after acute cerebral ischemia induced by bilateral carotid ligation (BCL) in spontaneously hypertensive rats (SHR). Blood glucose levels were varied by intraperitoneal infusion of 50% of glucose (hyperglycemia), insulin with hypertonic saline (hypoglycemia) or hypertonic saline (normoglycemia). Cerebral blood flow (CBF) in the parietal cortex and thalamus was measured by hydrogen clearance technique, and the supratentorial metabolites of the brain frozen in situ were determined by the enzymatic method. In non-ischemic animals, blood glucose levels had no influence on the supratentorial lactate, pyruvate or adenosine triphosphate (ATP) concentrations. In ischemic animals, however, cortical CBF was reduced to less than 1% of the resting value at 3 hours after BCL. However, there were no substantial differences of CBF during and after ischemia among 3 glycemic groups. Cerebral lactate in the ischemic brain greatly increased in hyperglycemia (34.97 +/- 1.29 mmol/kg), moderately in normoglycemia (23.43 +/- 3.13 mmol/kg) and less in hypoglycemia (7.20 +/- 1.54 mmol/kg). In contrast, cerebral ATP decreased in hyperglycemia (0.93 +/- 0.19 mmol/kg) as much as it did in normoglycemia (1.04 +/- 0.25 mmol/kg), while ATP reduction was much greater in hypoglycemia (0.45 +/- 0.05 mmol/kg). At 1-hour recirculation after 3-hour ischemia, ATP tended to increase in all groups of animals, indicating the recovery of energy metabolism. Such metabolic recovery after recirculation was good in hypo- and normoglycemia, and was also evident in hyperglycemia. Our results suggest that hyperglycemia is not necessarily an unfavorable condition in acute incomplete cerebral ischemia.     

Cerebral hemodynamics: concepts of clinical importance

Cerebral hemodynamics and metabolism are frequently impaired in a wide range of neurological diseases, including traumatic brain injury and stroke, with several pathophysiological mechanisms of injury. The resultant uncoupling of cerebral blood flow and metabolism can trigger secondary brain lesions, particularly in early phases, consequently worsening the patient's outcome. Cerebral blood flow regulation is influenced by blood gas content, blood viscosity, body temperature, cardiac output, altitude, cerebrovascular autoregulation, and neurovascular coupling, mediated by chemical agents such as nitric oxide (NO), carbon monoxide (CO), eicosanoid products, oxygen-derived free radicals, endothelins, K+, H+, and adenosine. A better understanding of these factors is valuable for the management of neurocritical care patients. The assessment of both cerebral hemodynamics and metabolism in the acute phase of neurocritical care conditions may contribute to a more effective planning of therapeutic strategies for reducing secondary brain lesions. In this review, the authors have discussed concepts of cerebral hemodynamics, considering aspects of clinical importance.     

血压波动对脑梗死后脑灌注的影响

本文主要从脑血管的自动调节与自动调节受损、脑小血管病变可导致脑血管反应性受损、脑梗死患者脑血流速度、脑血流量与血压的相关性,脑梗死侧大脑半球脑灌注降低、低血压对脑主要动脉狭窄者可导致狭窄远端脑组织局部低灌注等几个方面来讨论脑梗死后血压的变化对脑血流速度、脑血流量的影响。给临床医生提出一个思考问题,在脑梗死的急性期把血压控制在多少才是最合适的水平,对患者的功能恢复最有益。     

Effects of acetazolamide on cerebral blood flow, blood volume, and oxygen metabolism: a positron emission tomography study with healthy volunteers.

To evaluate changes in cerebral hemodynamics and metabolism induced by acetazolamide in healthy subjects, positron emission tomography studies for measurement of cerebral perfusion and oxygen consumption were performed. Sixteen healthy volunteers underwent positron emission tomography studies with 15O-gas and water before and after intravenous administration of acetazolamide. Dynamic positron emission tomography data were acquired after bolus injection of H2[15O] and bolus inhalation of 15O2. Cerebral blood flow, metabolic rate of oxygen, and arterial-to-capillary blood volume images were calculated using the three-weighted integral method. The images of cerebral blood volume were calculated using the bolus inhalation technique of C[15O]. The scans for cerebral blood flow and volume and metabolic rate of oxygen after acetazolamide challenge were performed at 10, 20, and 30 minutes after drug injection. The parametric images obtained under the two conditions at baseline and after acetazolamide administration were compared. The global and regional values for cerebral blood flow and volume and arterial-to-capillary blood volume increased significantly after acetazolamide administration compared with the baseline condition, whereas no difference in metabolic rate of oxygen was observed. Acetazolamide-induced increases in both blood flow and volume in the normal brain occurred as a vasodilatory reaction of functioning vessels. The increase in arterial-to-capillary blood volume made the major contribution to the cerebral blood volume increase, indicating that the raise in cerebral blood flow during the acetazolamide challenge is closely related to arterial-to-capillary vasomotor responsiveness.     

Cerebral Lactate Metabolism After Traumatic Brain Injury

Cerebral energy dysfunction has emerged as an important determinant of prognosis following traumatic brain injury (TBI). A number of studies using cerebral microdialysis, positron emission tomography, and jugular bulb oximetry to explore cerebral metabolism in patients with TBI have demonstrated a critical decrease in the availability of the main energy substrate of brain cells (i.e., glucose). Energy dysfunction induces adaptations of cerebral metabolism that include the utilization of alternative energy resources that the brain constitutively has, such as lactate. Two decades of experimental and human investigations have convincingly shown that lactate stands as a major actor of cerebral metabolism. Glutamate-induced activation of glycolysis stimulates lactate production from glucose in astrocytes, with subsequent lactate transfer to neurons (astrocyte-neuron lactate shuttle). Lactate is not only used as an extra energy substrate but also acts as a signaling molecule and regulator of systemic and brain glucose use in the cerebral circulation. In animal models of brain injury (e.g., TBI, stroke), supplementation with exogenous lactate exerts significant neuroprotection. Here, we summarize the main clinical studies showing the pivotal role of lactate and cerebral lactate metabolism after TBI. We also review pilot interventional studies that examined exogenous lactate supplementation in patients with TBI and found hypertonic lactate infusions had several beneficial properties on the injured brain, including decrease of brain edema, improvement of neuroenergetics via a “cerebral glucose-sparing effect,” and increase of cerebral blood flow. Hypertonic lactate represents a promising area of therapeutic investigation; however, larger studies are needed to further examine mechanisms of action and impact on outcome.