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The rationale for perioperative brain protection

Published online by Cambridge University Press:  23 December 2004

P. Hans  and
V. Bonhomme
P. Hans
Affiliation:
Liege University Hospital, University Department of Anaesthesia and Intensive Care Medicine, CHR de la Citadelle, Belgium
V. Bonhomme
Affiliation:
Liege University Hospital, University Department of Anaesthesia and Intensive Care Medicine, CHR de la Citadelle, Belgium
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Extract

Summary

Perioperative brain protection refers to prophylactic measures instituted during the perioperative period to prevent or reduce ischaemic damage and to improve neurological outcome. In that context, strategies for protecting the brain rely on the control of physiological variables, anaesthesia, administration of non-anaesthetic pharmacological agents and preconditioning. Avoiding hyperthermia, hyperglycaemia and arterial hypotension are passive neuroprotective measures acknowledged in human beings. The protective effect of anaesthesia, compared to the awake state, is demonstrated in animals but remains to be validated in clinical practice. Laboratory studies investigating pharmacological neuroprotection have shown interesting results but most clinical trials have been disappointing except for a few drugs in specific settings. Preconditioning which results in the induction of some resistance to ischaemia appears as a promising strategy. Up to now, the translation of beneficial experimental results into clinical success is considered an entirely permissible hope but remains an unachieved objective.

Keywords

CENTRAL NERVOUS SYSTEM DEPRESSANTS, anaestheticsBODY TEMPERATURE CHANGES, hypothermiaCEREBROVASCULAR DISORDERS, hypoxia–ischaemia, brainSURGICAL PROCEDURES, OPERATIVE, intraoperative period
Type
Review
Information
European Journal of Anaesthesiology , Volume 21 , Issue 1 , January 2004 , pp. 1 - 5
Copyright
2004 European Society of Anaesthesiology

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References

The Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. New Engl J Med 2002; 346: 549–556.
Clifton GL, Miller ER, Choi SC, et al. Lack of effect of induction of hypothermia after acute brain injury. New Engl J Med 2001; 344: 556–563.Google Scholar
Hindman BJ, Todd MM, Gelb AW, et al. Mild hypothermia as a protective therapy during intracranial aneurysm surgery: a randomized prospective pilot trial. Neurosurgery 1999; 44: 23–32.Google Scholar
Schwab S, Schwarz S, Spranger M, Keller E, Bertram M, Hacke W. Moderate hypothermia in the treatment of patients with severe middle cerebral artery infarction. Stroke 1998; 29: 2461–2466.Google Scholar
Szczudlik A, Slowik A, Turaj W, et al. Transient hyperglycemia in ischemic stroke patients. J Neurol Sci 2001; 189: 105–111.Google Scholar
Van Den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. New Engl J Med 2001; 345: 1359–1367.Google Scholar
Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993; 34: 216–222.Google Scholar
Chang HS, Hongo K, Nakagawa H. Adverse effects of limited hypotensive anesthesia on the outcome of patients with subarachnoid hemorrhage. J Neurosurg 2000; 92: 971–975.Google Scholar
Wells B, Keats A, Cooley D. Increased tolerance to cerebral ischemia produced by general anaesthesia during temporary carotid occlusion. Surgery 1963; 54: 216–223.Google Scholar
Goldstein A, Wells B, Keats A. Increased tolerance to cerebral anoxia by pentobarbital. Arch Int Pharmacodyn Ther 1996; 161: 138–143.Google Scholar
Cole DJ, Shapiro HM, Drummond JC, Zivin JA. Halothane, fentanyl/nitrous oxide, and spinal lidocaine protect against spinal cord injury in the rat. Anesthesiology 1989; 70: 967–972.Google Scholar
Warner DS, McFarlane C, Todd MM, Ludwig P, McAllister AM. Sevoflurane and halothane reduce focal ischemic brain damage in the rat. Possible influence on thermoregulation. Anesthesiology 1993; 79: 985–992.Google Scholar
Warner DS, Ludwig PS, Pearlstein R, Brinkhous AD. Halothane reduces focal ischemic injury in the rat when brain temperature is controlled. Anesthesiology 1995; 82: 1237–1245.Google Scholar
Miura Y, Grocott HP, Bart RD, Pearlstein RD, Dexter F, Warner DS. Differential effects of anesthetic agents on outcome from near-complete but not incomplete global ischemia in the rat. Anesthesiology 1998; 89: 391–400.Google Scholar
Gelb AW, Bayona NA, Wilson JX, Cechetto DF. Propofol anesthesia compared to awake reduces infarct size in rats. Anesthesiology 2002; 96: 1183–1190.Google Scholar
Schwab S, Spranger M, Schwarz S, Hacke W. Barbiturate coma in severe hemispheric stroke: useful or obsolete? Neurology 1997; 48: 1608–1613.Google Scholar
Nussmeier NA, Arlund C, Slogoff S. Neuropsychiatric complications after cardiopulmonary bypass: cerebral protection by a barbiturate. Anesthesiology 1986; 64: 165–170.Google Scholar
Zaidan JR, Klochany A, Martin WM, Ziegler JS, Harless DM, Andrews RB. Effect of thiopental on neurologic outcome following coronary artery bypass grafting. Anesthesiology 1991; 74: 406–411.Google Scholar
Wilson JX, Gelb AW. Free radicals, antioxidants, and neurologic injury: possible relationship to cerebral protection by anesthetics. J Neurosurg Anesthesiol 2002; 14: 66–79.Google Scholar
Roach GW, Newman MF, Murkin JM, et al. Abstract Ineffectiveness of burst suppression therapy in mitigating perioperative cerebrovascular dysfunction. Multicenter Study of Perioperative Ischemia (McSPI) Research Group. Anesthesiology 1999; 90: 1255–1264.Google Scholar
Lei B, Popp S, Capuano-Waters C, Cottrell JE, Kass IS. Effects of low-dose lidocaine on cytochrome c release and caspase-3 activation after transient focal cerebral ischemia in rats. Anesthesiology, 2002; ASA Meeting Abstracts, A-800.Google Scholar
Mitchell SJ, Pellett O, Gorman DF. Cerebral protection by lidocaine during cardiac operation. Ann Thorac Surg 1999; 67: 1117–1124.Google Scholar
Warner DS, McFarlane C, Todd MM, Ludwig P, Mc Allister AM. Sevoflurane and halothane reduce focal ischemic brain damage in the rat. Anesthesiology 1993; 79: 985–992.Google Scholar
Werner C, Möllenberg O, Kochs E, Schulte am Esch J. Sevoflurane improves neurological outcome after incomplete cerebral ischaemia in rats. Br J Anaesth 1995; 75: 756–760.Google Scholar
Engelhard K, Werner C, Reeker W, et al. Desflurane and isoflurane improve neurological outcome after incomplete cerebral ischaemia in rats. Br J Anaesth 1999; 83: 415–421.Google Scholar
Sullivan BL, Leu D, Taylor DM, Fahlman CS, Bickler PE. Isoflurane prevent delayed cell death in an organotypic slice culture model of cerebral ischemia. Anesthesiology 2002; 96: 189–195.Google Scholar
Engelhard K, Eberspächer E, Bachl M, Werner C, Kochs E. Sevoflurane influences the expression of apoptosis-regulating proteins after cerebral ischemia in rats over time. J Neurosurg Anesthesiol 2002; 14: 336.Google Scholar
Wilhelm S, Ma D, Mae M, Franks NP. Effects of Xenon on in vitro and in vivo models of neuronal injury. Anesthesiology 2002; 96: 1485–1491.Google Scholar
Pickard JD, Murray GD, Illingworth R, et al. Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial. BMJ 1989; 298: 636–642.Google Scholar
Barker IIFB, Ogilvy CS. Efficacy of prophylactic nimodipine for delayed ischemic deficit after subarachnoid hemorrhage: a metaanalysis. J Neurosurg 1996; 84: 405–414.Google Scholar
Feigin VL, Rinkel GJ, Algra A, Vermeulen M, van Gijn J. Calcium antagonists for aneurismal subarachnoid haemorrhage. Cochrane Database System Review 2000; 2: CD000277.Google Scholar
Ahmed N, Nasman P, Wahlgren NG. Effect of intravenous nimodipine on blood pressure and outcome after acute stroke. Stroke 2000; 31: 1250–1255.Google Scholar
Horn J, de Haan RJ, Vermeulen M, Limburg M. Very early nimodipine use in stroke (VENUS): A randomized, double-blind, placebo-controlled trial. Stroke 2001; 32: 461–465.Google Scholar
Marinov MB, Harbaugh KS, Hoopes PJ, Pikus HJ, Harbaugh RE. Neuroprotective effects of preischemia intraarterial magnesium sulfate in reversible focal cerebral ischemia. J Neurosurg 1996; 85: 117–124.Google Scholar
Feldman Z, Gurevitch B, Artru AA, et al. Effect of magnesium given 1 hour after head trauma on brain edema and neurological outcome. J Neurosurg 1996; 85: 131–137.Google Scholar
Heath DL, Vink R. Improved motor outcome in response to magnesium therapy received up to 24 hours after traumatic diffuse axonal brain injury in rats. J Neurosurg 1999; 90: 504–509.Google Scholar
Muir KW. Magnesium for neuroprotection in ischaemic stroke: rationale for use and evidence of effectiveness. CNS Drug 2001; 15: 921–930.Google Scholar
Arrowsmith JE, Harrison MJG, Newman SP, Stygall J, Timberlake N, Pugsley WB. Neuroprotection of the brain during cardiopulmonary bypass. A randomized trial of remacemide during coronary artery bypass in 171 patients. Stroke 1998; 29: 2357–2362.Google Scholar
Nishio S, Yunoki M, Chen ZF, Anzivino MJ, Lee KS. Ischemic tolerance in the rat neocortex following hypothermic preconditioning. J Neurosurg 2000; 93: 845–851.Google Scholar
Xiong L, Zhu Z, Dong H, Hu W, Hou L, Chen S. Hyperbaric oxygen preconditioning induces. Chin Med J 2000; 113: 836–839.Google Scholar
Weih M, Kallenberg K, Bergk A, et al. Attenuated stroke severity after prodromal TIA. A role for ischemic tolerance in the brain? Stroke 1999; 30: 1851–1854.Google Scholar
Moncayo J, de Freitas GR, Bogousslavsky J, Altieri M, van Melle G. Do transient ischemic attacks have a neuroprotective effect? Neurology 2000; 54: 2089–2094.Google Scholar
McPherson BC, Yao Z. Morphine mimics preconditioning via free radical signals and mitochondrial KATP channels in myocytes. Circulation 2001; 103: 290–295.Google Scholar
Zaugg M, Lucchinetti E, Spahn DR, Pasch T, Schaub MC. Volatile anesthetics mimic cardiac preconditioning by priming the activation of mitochondrial KATP channels via multiple signaling pathways. Anesthesiology 2002; 97: 4–14.Google Scholar
Blanck TJ, Haile M, Xu F. Isoflurane pre-treatment ameliorates postischemic neurologic dysfunction and preserves hippocampal Ca2+/calmodulin-dependent protein kinase in a canine cardiac arrest model. Anesthesiology 2000; 93: 1285–1293.Google Scholar
Bhardwaj A, Castro IIIAF, Alkayed NJ, Hurn PD, Kirsch JR. Anesthetic choice of halothane versus propofol: impact on experimental perioperative stroke. Stroke 2001; 32: 1920–1925.Google Scholar
De Hert SG, ten Broecke PW, Mertens E, et al. Sevoflurane but not propofol preserves myocardial function in coronary surgery patients. Anesthesiology 2002; 97: 42–49.Google Scholar
Sirén AL, Ehrenreich H. Erythropoietin – a novel concept for neuroprotection. Eur Arch Psychiat Clin Neurosci 2001; 251: 179–184.Google Scholar