Eduardo H. Rubinstein

Cerebrovascular Anatomy and Blood Flow Measurements in the Rabbit

The arterial supply and venous drainage of the rabbits brain were characterized by intravascular injection of casting material and intra-arterial administration of markers (crystal violet or dissolved hydrogen gas). The internal carotid artery supplies the homolateral cerebral cortex and subcortical structures except for the thalamus and the posterior portion of the nucleus caudatus; it also supplies the homolateral retina and optic nerve. No noncerebral structures are supplied by this artery. The dorsal sagittal sinus drains the dorsal and lateral parts of the frontal and parietal areas of the cerebral cortex, with no detectable extracerebral contamination. Electromagnetic measurement of flow in the internal carotid artery (ICBF), volumetric or H2-clearance measurement of flow in the dorsal sagittal sinus (SSBF), and H2-clearance determination in cerebral cortex yield comparable results on the cerebrovascular response to hyper- and hypocapnia. ICBF and SSBF are reliable and valid estimates of average blood flow through the homolateral cerebral hemisphere and the cerebral cortex, respectively.

Visceral and behavioral responses to intraduodenal fat.

Introduction of milk or corn oil into the duodenum of the cat evokes an increase in superior mesenteric blood flow (blocked by atropine), an inhibition of gastric and duodenal motility, and sedation. Cholecystokinin-pancreozymin mimics the mesenteric vascular effect of intraduodenal fat and seems to have a sedating action.

Topographical and temporal specificity of human intraoperative optical intrinsic signals

THE goal of this study was to determine the topographical and temporal specificity of neuronal and vascular responses using an intraoperative optical technique (iOIS). The face, thumb, index, and middle fingers were stimulated individually to obtain separate maps of cortical activation. Peak optical responses provided unique, non-overlapping cortical brain maps. Non-peak signals were more dispersed and produced overlapping responses from different digits. Peak iOIS responses colocalized with electrocortical stimulation mapping and evoked potentials. Temporally, we observed statistically significant specificity corresponding to sequential cortical activation during early optical signals (500–1750 ms), but later perfusion responses were non-specific. To our knowledge, this is the first report of either topographical specificity in overlapping spatial patterns, and/or temporal specificity in early perfusion profiles. These results therefore may have significant implications for other perfusion dependent functional imaging techniques.

Intraoperative Identification of Laryngeal Nerves With Laryngeal Electromyography

The laryngeal nerves are at risk during thyroid surgery, and several techniques have been described for their intraoperative identification to minimize potential damage. Nerve protection is based on the electromyographic recording from the muscles innervated by the laryngeal nerves, and that electrical activity is picked up by various techniques. We evaluated an electrode attachment to the endotracheal tube that provides a stable method for continuous recording of the laryngeal electromyogram. In addition, we tested various modalities of electrical stimulation in the region where the nerves are located, identified the most reliable evoked electromyographic activity, and characterized the wave form and latency. The results, obtained in 28 patients scheduled for thyroid and parathyroid surgery, indicate that the technique of recording from electrodes attached to the endotracheal tube is safe and reliable. Insulated bipolar forceps or a monopolar electrode was used to deliver low‐voltage pulses (1 to 3 V) at 1 to 2 pulses/s generated by either battery‐operated or optically isolated stimulators. The most unequivocal recordings were obtained with the monitoring equipment set to the nerve‐conduction velocity modality, with the sweep set at 2 msec/cm. The technique clearly differentiated the evoked electromyographic responses obtained from the superior or recurrent laryngeal nerve and was easily performed with no perioperative complications.

Cholinergic Cerebral Vasodilatation in the Rabbit: Absence of Concomitant Metabolic Activation

Cerebral blood flow (CBF) was estimated from measurements of internal carotid blood flow and sagittal sinus blood flow in mechanically ventilated rabbits under 70% N2O–30% O2. Intravenously administered physostigmine, a cholinesterase inhibitor, increased CBF under normocapnia and enhanced the cerebral vasodilatation of hypercapnia, but did not alter the cerebral metabolic rate of oxygen (CMRO2). The cerebrovascular effects of physostigmine were antagonized by atropine but not by dihydro-beta-erythroidine, a nicotinic blocker. Neostigmine, a quaternary cholinesterase inhibitor that does not cross the blood-brain barrier, showed no cerebrovascular effects, It is concluded that the cholinergic cerebral vasodilatation does not depend on cerebral metabolic activation, and that the cholinergic receptors involved are muscarinic and located beyond the blood-brain barrier.

The Electroencephalogram, Blood Flow, and Oxygen Uptake in Rabbit Cerebrum

In the present study, the relationships among electroencephalographic (EEG) amplitude shifts, cerebral blood flow (CBF), and cerebral oxygen uptake (CMRO2) have been characterized in halothane-anesthetized rabbits. CBF was measured by timed collection of venous effluent from the superior sagittal sinus. CMRO2 was calculated as the product of CBF and the arteriovenous difference in oxygen content. The depth of anesthesia in the first series of experiments was maintained at a constant level that was characterized by spontaneous EEG shifts from high- to low-voltage states (HV-LV shifts). These shifts were associated with transient decreases in mean arterial pressure (MAP), which averaged 23 ± 2 mm Hg (n = 17). Ninety seconds after spontaneous HV-LV shifts, MAP had returned to its original value, CBF had increased by 26 ± 7% (n = 8), and CMRO2 had increased 22 ± 4% (n = 7). In a second series of experiments, HV-LV shifts were induced by a 90-s application of a standardized nociceptive stimulus (n = 13). Following these stimulation-induced HV-LV shifts, CBF increased 28 ± 5% and CMRO2 increased 27 ± 4%. Under scopolamine (0.35 mg/kg, i.v., n = 8), no change in CBF was observed following HV-LV shifts induced by 90-s of stimulation, although CMRO2 increased significantly by 14 ± 3%. After 300 s of post-scopolamine stimulation, however, both CBF and CMRO2 had significantly increased by 12 ± 3 and 15 ± 3% (n = 8) of control, respectively. These results demonstrate that HV-LV shifts, whether spontaneous or stimulation-induced, are associated with significant increases in both CBF and CMRO2. Because the early (90-s) increases in CBF but not those in CMRO2 could be blocked by scopolamine, we suggest that the cerebral vasodilatation that occurs during the early phase of HV-LV shifts involves cholinergic mechanisms. Because scopolamine could not block the increase in CBF observed after 300 s of stimulation, we suggest that the final value of CBF obtained after an HV-LV shift is determined by a combination of both cholinergic and noncholinergic factors.

The Relationship of Pulsatile Cerebrospinal Fluid Flow to Cerebral Blood Flow and Intracranial Pressure: A New Theoretical Model

An electrical-equivalent circuit model of the cerebrovascular system is proposed, components of which directly relate to cerebrospinal fluid (CSF) compartment compliance and the determination of intracranial pressure (ICP). The model is based on three premises: 1) Under normal, physiologic conditions, the conversion of pulsatile arterial to nonpulsatile venous flow occurs primarily as a result of arterial compliance. Nonpulsatile venous flow is advantageous because less energy is required to maintain constant flow through the venous system, which comprises 75-80% of total blood volume. 2) Dynamic CSF movement across the foramen magnum is the primary facilitator by which intracranial arterial expansion occurs. Interference of the displacement of CSF during systole results in pulsatile venous flow and increased venous flow impedance. 3) Tissue hydrostatic pressure (here defined as ICP) is a dependent variable which is a function of capillary hydrostatic pressure and the osmotic/oncotic pressure gradient created by the blood-brain-barrier (BBB). An interference of transcranial CSF movement results in a decrease in cerebral blood flow (CBF) due to inertial effects impeding pulsatile venous flow. Feedback regulation in response to this decreased CBF leads to arteriolar vasodilatation (decreased resistance), thereby lowering the pressure difference between internal carotid and capillary pressures. Assuming no changes in the BBB potential, ICP increases linearly as capillary pressure increases.

Gas and Air Embolization during Hysteroscopic Electrosurgical Vaporization: Comparison of Gas Generation Using Bipolar and Monopolar Electrodes in an Experimental Model

STUDY OBJECTIVE To compare the composition of gases generated by bipolar hysteroscopic vaporizing electrodes using electrolyte-rich medium (normal saline) with those of monopolar vaporizing electrodes using nonelectrolytic medium (1.5% glycine). DESIGN In vitro study (Canadian Task Force classification II-1). SETTING Laboratory. INTERVENTION Fresh morbid bovine cardiac muscle was fully immersed in normal saline for the bipolar vaporizing electrode and 1.5% glycine for the monopolar vaporizing electrode. Standard hysteroscopic electrodes were activated at usual and maximum power outputs from radiofrequency electrosurgical generators appropriate for each system. The gases generated were captured and analyzed by gas chromatography and fast Fourier transform. MEASUREMENTS AND MAIN RESULTS Gaseous by-products of electrosurgical vaporization of test tissues largely consisted of hydrogen, carbon monoxide, and carbon dioxide. The composition of gases generated by hysteroscopic monopolar and bipolar electrodes in this laboratory model appear to be similar. CONCLUSION These gases are all highly soluble in serum. This observation suggests that emboli of gaseous by-products of electrosurgery are unlikely to have an adverse impact on patients. On the other hand, air emboli, largely composed of relatively insoluble nitrogen, are more likely to result in clinically significant cardiopulmonary events.

Measurement of Cardiac Output with Indocyanine Green Transcutaneous Fluorescence Dilution Technique

Background: Cardiac output is an essential parameter for the hemodynamic assessment of patients with cardiovascular disease. The authors tested in an animal model the feasibility of measuring cardiac output by transcutaneous fluorescence monitoring of an intravenous bolus injection of indocyanine green. Methods: Fluorescence dilution cardiac output was measured in 10 anesthetized rabbits and compared with cardiac output measured with a pulmonary thermodilution catheter and to aortic velocity measured by Doppler ultrasound. Indocyanine green fluorescence was excited with a near-infrared laser and measured with an optical probe positioned on the central ear artery. Measurements were obtained during baseline conditions as well as during short-term decreases and increases of the cardiac output. Results: The fluorescence of circulating indocyanine green detected transcutaneously varied proportionally to that of arterial blood samples, which allowed for calibration in terms of blood concentration of indocyanine green. Average values of fluorescence dilution cardiac output and thermodilution cardiac output measured in baseline conditions were 412 (± 13) and 366 (± 11) ml/min, respectively. Fluorescence dilution cardiac output showed a close, one-to-one linear relation with thermodilution cardiac output in each animal and in the pooled data from all animals (slope = 0.95 × 0.03; R = 0.94). Fluorescence dilution cardiac output overestimated thermodilution cardiac output by an average of 46 (± 6) ml/min during baseline conditions. Fluorescence dilution cardiac output was tightly correlated with aortic velocity. Conclusions: The proposed technique yielded accurate estimates of the cardiac output in experimental animals. This study should provide an initial framework for clinical testing of this new minimally invasive method for measuring cardiac output.

Transcutaneous fluorescence dilution cardiac output and circulating blood volume during hemorrhagic hypovolemia.

Background: Cardiac output and circulating blood volume are important parameters for assessing cardiac function in the intensive care setting and during major surgeries. The authors tested in an animal model of hemorrhagic hypovolemia the feasibility of measuring these parameters simultaneously by transcutaneous fluorescence monitoring of an intravenous bolus injection of indocyanine green. Methods: Fluorescence dilution cardiac output was measured in seven anesthetized rabbits and compared to thermodilution cardiac output. The optical probe used to excite the indocyanine green fluorescence was in contact with the skin above the ear artery. Local heating enhanced blood perfusion of the measurement site. Cardiac output was measured during baseline conditions, during hemorrhagic hypovolemia, and after partial restoration of the blood volume with reinfused blood. Estimates of the circulating blood volume were simultaneously obtained from the analysis of the fluorescence dilution traces. Results: Cardiac output measured by fluorescence dilution (thermodilution) averaged 455 ± 16 (450 ± 13) ml/min in baseline conditions and 323 ± 15 (330 ± 13) ml/min during hypovolemia. Fluorescence dilution cardiac output was linearly related to thermodilution cardiac output (slope = 1.13 ± 0.05, ordinate = −50 ± 19 ml/min, R = 0.92). Interanimal differences explained most of the variance between cardiac output estimates obtained with the two techniques. Circulating blood volume decreased from 204 ± 5 ml in baseline conditions to 174 ± 8 ml after bleeding and reflected blood volume changes in this acute bleeding–reinfusion model. Conclusions: The study extends the applicability of the fluorescence dilution technique for cardiac output measurement to hypovolemic conditions and demonstrates its ability to produce accurate estimates of the circulating blood volume in experimental animals.