Effects of stellate ganglion block on cerebrovascular vasodilation in elderly patients and patients with subarachnoid haemorrhage

Abstract

Editor—In 1936, Leriche and Fontaine first drew attention to the fact that stellate ganglion block (SGB) caused a ‘striking regression of symptoms in two cases of postoperative hemiplegia’.1Moore DC Stellate ganglion block—therapy for cerebral vascular accidents.Br J Anaesth. 2006; 96 (author reply 666–667): 666Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Since then, numerous studies have emphasized the usefulness of SGB to reduce the vascular spasm associated with cerebral thrombosis and embolism.1Moore DC Stellate ganglion block—therapy for cerebral vascular accidents.Br J Anaesth. 2006; 96 (author reply 666–667): 666Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Stellate ganglion block causes sympathetic inhibition of the ispilateral head, neck, upper thorax, and arms, resulting in peripheral vasodilation.2Hey M Wilson I Johnson MI Stellate ganglion blockade (SGB) for refractory index finger pain – a case report.Ann Phys Rehabil Med. 2011; 54: 181-188Crossref PubMed Scopus (10) Google Scholar However, its effects on cerebral haemodynamics, in ageing, or in subarachnoid haemorrhage (SAH) are not clear. This study demonstrates, for the first time, the importance of SGB to clarify age-related or SAH-related differences in vasospasm and the efficacy of SGB in relation to the responses of basilar arteries. Age is a major risk factor for a poor outcome in patients with cerebral vascular disease, including SAH.3Lanzino G Kassell NF Germanson TP et al.Age and outcome after aneurysmal subarachnoid hemorrhage: why do older patients fare worse?.J Neurosurg. 1996; 85: 410-418Crossref PubMed Scopus (297) Google Scholar4Pahl FH Oliveira MF Rotta JM Natural course of subarachnoid hemorrhage is worse in elderly patients.Arq Neuropsiquiatr. 2014; 72: 862-866Crossref PubMed Scopus (10) Google Scholar Recent studies have shown that the incidence of SAH in the elderly, especially those older than 60 yr of age, is increasing with the increased age of the general population.3Lanzino G Kassell NF Germanson TP et al.Age and outcome after aneurysmal subarachnoid hemorrhage: why do older patients fare worse?.J Neurosurg. 1996; 85: 410-418Crossref PubMed Scopus (297) Google Scholar4Pahl FH Oliveira MF Rotta JM Natural course of subarachnoid hemorrhage is worse in elderly patients.Arq Neuropsiquiatr. 2014; 72: 862-866Crossref PubMed Scopus (10) Google Scholar In the aged brain, there is a reduction in the angiogenesis response because of decreased responsiveness to hypoxia-inducible factor 1.5Ingraham JP Forbes ME Riddle DR Sonntag WE Aging reduces hypoxia-induced microvascular growth in the rodent hippocampus.J Gerontol A Biol Sci Med Sci. 2008; 63: 12-20Crossref PubMed Scopus (37) Google Scholar6Petcu EB Smith RA Miroiu RI Opris MM Angiogenesis in old-aged subjects after ischemic stroke: a cautionary note for investigators.J Angiogenes Res. 2010; 2: 26Crossref PubMed Scopus (43) Google Scholar Although the biological and medical consequences of a stroke are significant at any age, the incidence and severity of a stroke is significantly increased with age. Gupta and colleagues7Gupta MM Bithal PK Dash HH Chaturvedi A Mahajan RP Effects of stellate ganglion block on cerebral haemodynamics as assessed by transcranial Doppler ultrasonography.Br J Anaesth. 2005; 95: 669-673Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar and Jain and colleagues8Jain V Rath GP Dash HH Bithal PK Chouhan RS Suri A Stellate ganglion block for treatment of cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage – a preliminary study.J Anaesthesiol Clin Pharmacol. 2011; 27: 516-521Crossref PubMed Scopus (30) Google Scholar found that SGB decreases cerebral vascular tone without affecting the capacity of cerebral blood vessels to react to the changes in carbon dioxide or to autoregulate. Stellate ganglion block might have a therapeutic role in patients where cerebral insufficiency can be attributed to cerebral vasospasm. In the present study, after SGB a significant increase in the calibre of middle cerebral artery (MCA), vertebral artery (VA), and arteriae basilaris (BA) in adult patients and elderly patients was observed (Fig. 1). The increase in calibre of the MCA, VA, and BA in adult patients was higher than that in elderly patients. We also found that the calibre of the MCA, VA, and BA was increased in patients with or without SAH after treatment with SGB (Fig. 1). Interestingly, the increase in blood vessel calibre was larger in patients with SAH compared with patients without SAH. Importantly, SGB did not induce bleeding but reduced cerebral vasospasm. Taken together, these studies suggest the possibility that SGB might have potential use in the treatment or control of cerebral vascular accidents in both elderly patients and patients with SAH and might promisingly be applied clinically after further research. Further studies are needed to determine cerebral vascular changes through prolonged observation or by repeating the block in elderly patients and patients with SAH. None declared.