Cerebral Blood Flow: Mechanisms of Ischemia, Diagnosis, and Therapy PDF
Preview Cerebral Blood Flow: Mechanisms of Ischemia, Diagnosis, and Therapy
Series Editor: Jean-Louis Vincent Springer NewYork Berlin Heidelberg Barcelona HongKong London Milan Paris Tokyo CEREBRAL BLOOD FLOW Mechanisms of Ischemia, Diagnosis, and Therapy Volume Editor: Michael R.Pinsky, MD Professor ofAnesthesiology Director ofResearch, Division ofCritical Care Medicine Department ofAnesthesiology and Critical Care Medicine University ofPittsburgh Pittsburgh, Pennsylvania, USA Series Editor: Jean-Louis Vincent, MD, PhD, FCCM, FCCP Head, Department ofIntensive Care Erasme University Hospital Brussels, Belgium With 57 Figures and 17Tables Springer MichaelR.Pinsky,MD Professor ofAnesthesiology DirectorofResearch,Division ofCriticalCareMedicine Department ofAnesthesiologyandCriticalCareMedicine UniversityofPittsburgh Pittsburgh,PA15261 USA SeriesEditor: Jean-LouisVincent,MD,PhD,FCCM,FCCP Head,DepartmentofIntensiveCare ErasmeUniversityHospital RoutedeLennik808 B-I070Brussels Belgium LibraryofCongressCataloging-in-PublicationData Cerebralbloodflow:mechanismsofischemia,diagnosis,and therapy/M.Pinsky(ed.).p.;cm. (Updateinintensivecaremedicine,ISSN0933-6788;37)"Proceedingsofthe5thAnnualSymposiumon AppliedPhysiologyofthePeripheralCirculation,June9-11,2000,PittsburghHiltonandtower, Pittsburgh,PAn- Contentsp.Includesbibliographicalreferencesandindex. ISBN3540426841(softcover:alk.paper) I.Cerebralischemia-Congresses. 2.Cerebralcirculation-Congresses. I.Pinsky,MichaelR. II.SymposiumonAppliedPhysiologyofthePeripheralCirculation(5th:2000:Pittsburgh,Pa.) III.Series.[DNLM:I.CerebrovascularCirculation-Congresses. 2.Brain-bloodsupply-Congresses. 3.Ischemia- Congresses. WIUP66Hv.3720021 Printedonacid-free paper. ©2002Springer-VerlagBerlinHeidelberg. Allrightsreserved.Thisworkmaynotbetranslatedorcopiedinwholeorinpartwithoutthewrittenper mission ofthepublisher(Springer-VerlagNewYork,Inc.,175FifthAvenue,NewYork,NY10010,USA), exceptforbriefexcerptsinconnectionwithreviewsorscholarlyanalysis.Useinconnectionwithanyform ofinformationstorageandretrieval,electronicadaptation,computersoftware,orbysimilarordissimilar methodologynowknownorhereafterdevelopedisforbidden. Theuseofgeneraldescriptivenames,tradenames,trademarks,etc.,inthispublication,eveniftheformer arenotespeciallyidentified,isnottobetakenasasignthatsuchnames,asunderstoodbytheTradeMarks andMerchandiseMarksAct,mayaccordinglybeusedfreelybyanyone. Whiletheadviceandinformationinthisbookarebelievedtobetrueandaccurateatthedateofgoingto press,neithertheauthorsnortheeditorsnorthepublishercanacceptanylegalresponsibilityforanyerrors oromissionsthatmaybemade.Thepublishermakesnowarranty,expressorimplied,withrespecttothe materialcontainedherein. ProductionmanagedbyPROEDITGmbH,Heidelberg,Germany. TypesetbyTBS,Sandhausen,Germany. PrintedandboundbyMercedes-Druck,Berlin,Germany. PrintedinGermany. 9 8 7 6 5 4 3 2 1 ISSN0933-6788 ISBN3-540-42684-1 SPIN 10851568 Springer-Verlag NewYork Berlin Heidelberg AmemberofBertelsmannSpringerScience-BusinessMediaGmbH Preface Cerebral Blood Flow:QuantifyingConsciousness Although the heart may be the source ofenergy needed to generate blood flow,and otherorgans absolutelyessentialfornormalliving,thebrain isthereasonwearealive. Thecollectedbookchaptersareaimedataddressing thismost fundamentalorgan and its blood flow.These papers reflectdetailed descriptions ofsimilar topics presented over a two-day period as part of the 5th International Symposium on Applied Physiology of the Peripheral Circulation held in Pittsburgh, Pennsylvania, in June 2000.The symposium and this volume were organized into four distinct groupings that followinalogicalfashion. The initial papers focus on the basic unique physiologyand pathophysiologyof thecerebralcirculation,includingahistorical reviewofthemeans tomeasure cerebral bloodflowand itsimplications of the past 30years.Dr.WalterD.Obristwasone of the original investigators to use radiolabeled markers to assesscerebral blood flow. His equations and initial studies form an impressive introduction to where we are now.Aswith much of the body's specialorgans, the brain too has manycirculatory featuresuniquetoitself.Theseinclude theuniqueblood-brainbarrierfunction ofthe endothelium,localneural regulation control,and intracranial pressure effects.These specialissues,plusgeneticfactorsthat maypredispose individuals todeveloping cere bral aneurysm,make up the initial section ofthe monograph. The brainisunique in itsresponse to ischemia.Sinceneurons containvasoactive neurotransmitters,secondaryvasospasm mayoccur, increasing the zone ofischemia to a greater extent than the original ischemia or traumatic process induced. Furthermore,assessment of neuronal function during ischemia and itspotential for recoveryisproblematic.In this regard,the pioneeringworkbyDrs.Siesjo,Kochanek, and Gjeddehasledtoexcitingnewinsights and potentialdiagnostictools and thera peutic optionsthat shouldhavemeasurableimpacton future care.Genetic controlof the fundamental aspects of neuronal celldeath is described in the works from the StrokeInstituteofthe UniversityofPittsburgh.Dr.Safardevelopsthe impressivehis tory of cerebral resuscitation from temporary global brain ischemia seen in cardiac arrest.Thisdiscussion chronicles the history ofthe SafarCenterforresuscitationand Dr.Safar'sownworkincerebralcardiopulmonaryresuscitationoverthepast40years. These topics logicallylead to the concept of ischemicpenumbra: that portion ofthe brain rendered dysfunctional but not yet irreversibly injured. The chapter by Dr. Hossmanndescribesafundamental aspect ofcerebral ischemia and infarction. Once the processesofblood flowand ischemia/reperfusionare understood,what remain arediagnostic techniquesand therapeuticoptions.Theseissuescomprisethe finaltwosectionsofthebookand givethevolume itsdecidedlyclinicalflavor.Clearly, ifone isto diagnose and treat cerebral ischemia, itisessentialto quantifythe degree ofcerebralischemiaand itsevolution overtime.Otherwise,onlysuperficialinferences VI Preface on theefficacyofclinicaltrialscanbemade.Theseareasareofthe greatestinterest to the practicingphysician,butrequire an understandingofthe fundamental aspects of physiologyand pathophysiologyfrom the preceding sections to putinto context. Measures ofcerebral blood floware problematic.What may be interesting to a perfusionistand one focusing on intravascularpathologymaybe the structuralvas cularchangesinducedbythrombosisorembolism,hemorrhageortrauma. However, functional imaging of neuronal function, tissue oxygenation, and potential for neu ronal recoveryrepresentthe newimaging techniquesavailableto the clinician.These and better methods of structural imaging are described in the third section by the worker who developed thesetechnologies and arepositionedinsuch asequence that theyproceed from structuralto functional imaging. Presently,many largemulticenteredclinicaltrials ofstroke prevention and treat ment have been completed and some new trials proposed. In the final section, we gather the principal investigators for severalof these clinicaltrials. They presentthe resultsforthrombolysis,interventionalneuroradiology,therapeutichypothermia,and revascularization surgery.This isclearlythe bleeding edgeofclinicalstudies on cere bral ischemia management. The clinicalchallengesin cerebral ischemia and stroke research remain the rapid and accurate diagnosis ofischemic injuryinatimely fashion and the institution and titration ofeffectivetherapies.Data presented therein suggestthat different imaging techniquesdescribedifferentaspectsofcerebralischemiaand thateachtechniquehas itsspecificstrengths and weaknesses.Importantly, based on our present-dayknowl edgeofischemicstrokeand itsnaturalhistory,therapiesto reverseischemiaand pre ventsubsequentinjurymaybequite different.Thissuggeststhatcombinationtherapy with differing goals early on and then into active therapy is a realistic option. Regrettably,the largemulticenteredclinicaltrialsdescribed inthis book areallofsin gletherapies.Thougheachhasaclearefficacyinspecificpatients, combinationther apywilllikelyemerge and willbethe most cost-effectiveapproach to treatment.Our challengewillbedefining the specificcombinationorgroupofcombinationsneeded ateachpointinthe treatment regimen andthe diagnostictestsor clinicalframework thatwillidentify thesespecificpatientgroups and theirsubsequentresponse to ther apy.Thischallengeisdaunting,butourunderstandingofthepathophysiologyofcere bral injury is increasing rapidly, our tools not only powerful but becoming more specificand noninvasive,and ourtreatmentoptionsmore process-specific.Thus, we canfeeloptimisticthat morbidityand mortalityfrom ischemicstrokewillcontinueto decline. Potentially, our ease in diagnosis and rapidity of effective treatment of ischemicbrain injury willbecome welldescribedand practicedasisour present-day diagnosis and treatmentforacute myocardial ischemia. Pittsburgh,Pennsylvania,USA MichaelR.Pinsky, MD Autumn2001 Contents Preface v MichaelR.Pinsky Contributors Xl Section1.Physiologyand Pathophysiology Chapter 1.HistoryofCerebral BloodFlowAssessment........................................ 3 WalterD.Obrist Chapter2.Neural Regulation ofthe Cerebral Circulation.................................... 7 CostantinoIadecola andKiyoshiNiwa Chapter3.RoleofEndothelium in Regulation ofthe BrainMicrocirculation... 17 FrankM.Faraci Chapter4.Molecular PathogeneticsofCerebral Aneurysms: Current Conceptsand Future Directions 26 AminB.Kassam,DavidG. Peters, andMichaelB.Horowitz Section2.IschemicBrain Injury Chapter5.TriggeringEventsin IschemicBrain Injury......................................... 45 BoK.Siesjo,TiborKristian, andHiroyuki Uchino Chapter6.Ischemic Mechanisms in Traumatic BrainInjury............................... 60 PatrickM.Kochanek,KristyS.Hendrich, KimberlyD.Statler, RobertS.B.Clark,Larry \JV, Jenkins, DonaldS.Williams,Chien Ho, andDonald\JV,Marion Chapter7.CouplingandCompartmentation ofCerebral BloodFlow and Metabolism........................................................................................................ 72 AlbertGjedde Chapter8.The Genetic ControlofIschemic NeuronalCellDeath...................... 96 StevenH.GrahamandRobert\JV, Hickey Chapter9.Cerebral Resuscitation from TemporaryComplete GlobalBrainIschemia 106 PeterSafar viii Contents Chapter 10.The IschemicPenumbra:Pathophysiology and TherapeuticImplications 137 Konstantin-AlexanderHossmann Section3.AssessmentofCerebral Blood Flow Chapter 11.TheAssessmentofDeterminantsofCerebral Oxygenation and Microcirculation 149 F.A. Pennings,G].Bouma, andCanlnce Chapter 12.Computed Tomography,Angiography,and Perfusion Imagingof AcuteStroke.................. 165 GeorgeHunter,LeenaM. Hamberg,MichaelH. Lev, andRamonGilbertoGonzales Chapter 13.The UseofXenon/CT CerebralBlood FlowStudies in Acute Stroke.............................................................................................................. 179 HowardYonas Chapter 14.Advances in Imagingin IschemicStroke 191 MajazMoonis andMarcFisher Chapter 15.Assessment ofCerebrovascular Pathophysiology 201 Viken Babikian,[oaoGomes,andjaroslawKrejza Chapter 16.Cerebral Blood Flow Measurementwith Positron EmissionTomography 217 William].Powers Section4.CurrentStatusofClinicalTrialsinAcuteStroke Chapter 17.ThrombolysisforAcuteStroke 229 LawrenceR.Wechsler Chapter 18.NeuroprotectiveStrokeTrials:ATen Year Dry Season 236 AlastairM.Buchan Chapter 19.InterventionalNeuroradiology inAcute IschemicStroke: Extracranialand IntracranialAngioplastyandStenting 252 RandallT. Higashida,AdelM. Malek,ConstantineC.Phatouros, ChristopherF. Dowd, andVan V. Halbach Contents ix Chapter20.TherapeuticModerateHypothermiaandFever 272 Donald WMarion Chapter21.CerebralHemodynamicsandStrokeRiskinPatientswithComplete CarotidArteryOcclusion.IsThereaRoleforCerebralRevascularization? 277 RobertL.Grubb,lr.. andWilliamJ. Powers SubjectIndex 299 Contributors Viken Babikian,MD MarcFisher, MD ProfessorofNeurology ViceChairman DepartmentofNeurology DepartmentofNeurology BostonUniversitySchoolofMedicine UniversityofMassachusettsMemorial Boston,Massachusetts Healthcare USA Worcester,Massachusetts USA G.]. Bouma, MD,PhD DepartmentofNeurosurgery AlbertGjedde, MD, DM,FAAAS AcademicMedicalCenter ThePathophysiologyandExperimental UniversityofAmsterdam TomographyCenter Amsterdam AarhusUniversityHospital TheNetherlands Aarhus Denmark AlastairM.Buchan, MD ProfessorofNeurology loaoGomes, MD DepartmentofClinicalNeurosciences ChiefResident UniversityofCalgary DepartmentofNeurology Calgary,Alberta BostonUniversitySchoolofMedicine Canada Boston,Massachusetts RobertS.B.Clark, MD USA AssistantProfessor RamonGilberto Gonzales, MD,PhD DepartmentofAnesthesiologyand CriticalCare AssociateProfessorofRadiology UniversityofPittsburghSchoolofMedicine DepartmentofRadiology Pittsburgh,Pennsylvania HarvardMedicalSchool USA Boston,Massachusetts USA ChristopherF. Dowd, MD AssociateClinicalProfessor Steven H.Graham,MD, PhD DepartmentofRadiologyand AssociateProfessor NeurologicalSurgery DepartmentofNeurology UniversityofCalifornia,SanFrancisco UniversityofPittsburghSchoolofMedicine SanFrancisco,California and USA AssociateDirectorforResearch GeriatricResearchEducationaland FrankM.Faraci, MD ClinicalCenter DepartmentsofInternalMedicineand VeteransAffairs PittsburghHealthSystem Pharmacology Pittsburgh,Pennsylvania UniversityofIowaCollegeofMedicine USA IowaCity,Iowa USA
The list of books you might like
