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PubMed2000

Long-term benefits of stellate ganglion block in severe chronic refractory angina.

Angina pectoris that is refractory to optimal medication and revascularization is becoming an increasingly common clinical problem. Recently the US Food and Drug Administration (FDA) approved transmyocardial laser revascularization (TMLR) for use in this group of patients and a large numbers of patients have already undergone this therapy. Unfortunately TMLR has is associated with an unacceptably high perioperative mortality (Cooley DA, Frazier OH, Kadipasaoglu KA, Lindenmeir MH, Pehlivanoglu S, KoIff JW, Wilansky S, Moore WH. Transmyocardiai laser revascularisation: clinical experience with twelve-month follow-up. J Thorac Cardiovasc Surg 1996;111:791-799; Horvath KA, Cohn LH, Cooley DA, Crew JR, Frazier GH, Griffith BP, Kadipasaoglu K, Lansing A, Mannting F, March R, Mirhoseini MR, Smith C. Transmyocardial laser revascularisation: results of a multi-centre transmyocardial laser revascularisation used as sole therapy for end-stage coronary artery disease. J Thorac Cardiovasc Surg 1997;113:645-654; Schofield PM, Sharples LD, Caine N, Burns S, Tait S, Wistow T, Buxton M, Wallwork J. Transmyocardial laser revascularisation in patients with refractory angina: a randomised controlled trial. Lancet 1999;353:519-524), and recurrent refractory angina is common (Allen KB, Dowling RD, Fudge TL, Schoettle GP, Selinger SL, Gangahar OM, Angell WW, Petracek MR, Shaar CJ, O'Neill WW. Comparison of transmyocardial revascularization with medical therapy in patients with refractory angina. N Engl J Med 1999;341:1021-1028; Frazier OH, March RJ, Horvath KA, for the Transmyocardial Carbon Dioxide Laser Revascularization Study Group. Transmyocardial revascularization with a carbon dioxide laser in patients with end-stage coronary artery disease. N Engl J Med 1999;341:1021-1028). Temporary sympathectomy by stellate ganglion block (SGB) is in widespread use in a variety of chronic pain conditions and has long history of use in the management of angina (Moore DC. Stellate ganglion block. Springfield, IL: CC Thomas, 1954; Wiener L, Cox JW. Influence of stellate ganglion blockade on angina pectoris and the post exercise electrocardiogram. Am J Med Sci 1966;252:289-295). Here we describe a patient with end stage coronary artery disease and chronic refractory angina whose has been successfully treated with repeated unilateral left SGBs following multiple bypass operations, angioplasty procedures and laser therapy. This case report details his progress over a 34 month follow-up period.

Anesthetics, Local↗
PubMed1997

[Subdural, extra-arachnoid block as a complication of stellate ganglion block: documentation with ultrasound].

We present a patient who developed a high central neural block after stellate-ganglion-blockade. The underlying pathophysiology was assessed via sonographic imaging. Stellate ganglion block was performed in a 19-year old patient according to the standard technique. Multiple aspiration tests were negative and a test dose of 3 ml bupivacaine 0.25% was injected. After a 3 min interval another 5 ml were injected. Two minutes after the local anaesthetic administration the patient reported nausea and sensations in the upper extremity. Spontaneous respiration efforts stopped, and the patient became unconscious. Tracheal intubation was performed, and the patient was ventilated in a controlled mode for two hours. Heart rate as well as blood pressure remained within the normal range. Neurologic recovery occurred rapidly and extubation was performed about two and a half hours after the event. Our sonographic studies demonstrated a local anaesthetic depot directly at the root of C 6, with a mean diameter of 10 mm and a length of 5 to 6 cm (about a third smaller than expected). Sonographic studies and clinical symptoms of our patient are most likely to occur with a subdural extra-arachnoidal block. Ultrasonographic guided puncture enhances the patient's safety by the opportunity to directly visualise transverse process, nerval root as well as local anaesthetic depot. In case of depot formation directly at the nerval root, injection may be stopped and the needle repositioned. Furthermore, direct visualisation of the great vessels (A. vertebralis) prevents intravascular injection and haematoma formation.

Adult↗
PubMedDate not supplied

Lymphocyte activation is attenuated by stellate ganglion block.

BACKGROUND AND OBJECTIVES: Clinical evidence suggests that stellate ganglion block (SGB) might modulate the immune system. Little is known, however, about the immunologic effects of SGB. We examined how SGB affected immune functions by analyzing the activation response of lymphocytes during SGB. METHODS: Twenty-four volunteers were randomly subdivided into three groups. The SGB group (SGB; n = 9) received 6 mL 1% lidocaine at the sixth cervical vertebra (C6) transverse process and showed Horner's sign and elevation of ipsilateral facial and upper limb temperature. The lidocaine group (n = 7) had 6 mL 1% lidocaine injected into subcutaneous tissue at the neck and showed no remarkable clinical effects. The saline group (placebo; n = 8) received 6 mL saline solution injected at approximately the C6 transverse process and showed no remarkable clinical effects. Peripheral blood samples were drawn before and 30 minutes after drug administration. Samples were incubated for 4 hours under the stimulation of mitogen. Using flow cytometry, we measured the de novo expression of CD69, which is one of the initial markers of lymphocyte activation and which reflects the cell activation process. The changes in pre- and post-values were calculated and compared among the three groups. RESULTS: In only the SGB group, the helper T-cell activation was significantly reduced, and the cytotoxic T-cell activation also tended to decrease after SGB. CONCLUSIONS: SGB may depress immune system activity for a short time, as reflected in the T-cell activation response.

Adult↗
PubMed1985

[Mechanisms of the inhibitory effect of the stellate ganglion on cardiac activity].

The mechanisms of cardiac activity inhibition caused by stimulation of the stellate ganglion were studied in acute experiments on 28 dogs and 37 cats and chronic experiments on 12 cats. It was shown that inhibition of cardiac activity is caused by stimulation of the parasympathetic fibers of the vagus, anastomozing with stellate ganglion branches and ingoing as part of these fibers to the heart. The hypothesis of change over of the sympathetic nerve fibers to the intracardial cholinergic neurons and the hypothesis of the cholinergic component in the mechanism of catecholamine release by the sympathetic nerve terminals was not confirmed. Therefore, the known Dale's principle as to that one neuron exerts its efferent effect with the aid of one transmitter is quite just. alpha-Adrenoreceptors does not produce any noticeable effect on cardiac activity.

Animals↗
PubMed1988

[Localization of neurons, making projections via the postganglionic nerves of the stellate ganglion].

Distribution of neurons, forming cardiac nerves of the cat stellate ganglion, has been investigated. The inferior cardiac nerve conducts inotropic influences to the heart. It is formed by the neurons localized in the caudal part of the ganglion. The caudal anastomosis conducts chronotropic influences to the heart. It is formed by the neurons localized in the inferior part of the ganglion and the ventral horn of the spinal nucleus and nucleus intercalatus. Axons of the preganglionic neurons pass through the ganglion and are not interrupted.

Animals↗
PubMed1993

Ultrastructural connectivity of [leu]5-enkephalin-immunoreactive synapses in the guinea-pig stellate ganglion: involvement of spines and triads.

The ultrastructure of [leu]5-enkephalin-immunoreactive (ENK-IR) nerve fibres in the guinea-pig stellate ganglion was studied by means of pre-embedding immunohistochemistry. ENK-immunoreactivity was primarily contained within large dense core vesicles (91 +/- 21 nm in diameter; n = 259) but was absent from small clear vesicles (47 +/- 9 nm; n = 488) within the same nerve terminal that were concentrated at presynaptic regions. Thus, fast synaptic transmission mediated by ENK-IR terminals most probably does not involve [leu]5-enkephalin which may be released parasynaptically. Evaluating a total number of 123 synapses involving an ENK-IR presynaptic nerve ending, 47% terminated upon a spine, 46% upon a dendritic shaft, and 7% directly addressed a soma of a postganglionic neuron. In 30% of axo-dendritic synapses and 33% of axo-somatic synapses, non-immunoreactive dendrites or somata being postsynaptic to an ENK-IR terminal were in direct but non-synaptic contact to another dendrite/soma. Such arrangements are termed "triads". In view of the current hypotheses concerning the function of spines and triads, these findings indicate that ENK-IR terminals within the guinea-pig stellate ganglion may be involved in the generation of long-lasting synaptic events and modulation of non-synaptic intraganglionic communication.

Animals↗
PubMed2006

Retropharyngeal hematoma after stellate ganglion block: Analysis of 27 patients reported in the literature.

BACKGROUND: Retropharyngeal hematoma (RPH) is rare; however, it causes airway obstruction and can be fatal. Stellate ganglion block (SGB) can cause RPH. The authors analyzed reports of patients with RPH after SGB to clarify the initial symptoms and signs, and the urgency of airway management. METHODS: MEDLINE and Japana Centra Revuo Medicina were searched for reports of RPH after SGB using the following terms and key words: stellate ganglion block, complication, hematoma, and retropharyngeal hematoma. RESULTS: The authors found 27 patients with RPH after SGB in the past 40 yr. The initial symptoms included neck pain (n = 10), dyspnea (n = 10), neck swelling (n = 8), and hoarseness (n = 5). The symptoms occurred 2 h or more after SGB in 14 patients (52%). Emergency airway management was needed in 21 patients (78%) because of airway obstruction. Among the 21 patients, orotracheal intubation was attempted first in 17 patients; however, it was unsuccessful in 5 patients who immediately needed emergency tracheostomy. Tracheal intubation was impossible by distortion of the anatomy of the markedly edematous pharyngolarynx. Failed airway management caused one death. There were no statistically significant predictors of the initial symptoms or signs for later emergency airway management. CONCLUSIONS: RPH after SGB necessitates emergency airway management. Because airway obstruction cannot be predicted by the initial symptoms or signs, emergency airway management tools should be at hand, and the patency of the airway should be continuously evaluated after onset of RPH after SGB.

Adult↗
PubMed1990

Innervation patterns of the middle cervical--stellate ganglion complex in the rat.

The present experiments were designed to clarify the distribution of innervation of the middle and inferior cervical ganglia in the rat (middle cervical-stellate ganglion complex), the sympathetic ganglia which give rise to virtually all cardiac sympathetic nerves. Seven or 28 days after middle cervical-stellate ganglionectomy (surgical sympathectomy) norepinephrine content was measured in 9 peripheral areas including both the left and right atria and ventricles of the heart. The results were also compared to chemical sympathectomy produced with 6-hydroxydopamine. Seven or 28 days after surgical sympathectomy norepinephrine concentrations were reduced in all cardiac regions by at least 94%. Norepinephrine concentration in sub-diaphragmatic (spleen), but not supra-diaphragmatic (left intrascapular fat, left forelimb muscle), non-cardiac organs was preserved at control levels. 6-Hydroxydopamine treatment significantly reduced the norepinephrine concentration in all of the cardiac and non-cardiac tissues. The present evidence indicates that the middle cervical-stellate ganglion complex in the rat projects to a rather limited number of peripheral organs. Additionally, surgical sympathectomy produces more selective cardiac sympathectomy than 6-hydroxydopamine.

Animals↗
PubMed1989

An ultrastructural study of the stellate ganglion of the pig-tailed monkey (Macaca nemestrina).

The stellate ganglia of Macaca nemestrina were studied with the electron microscope, using the conventional and chromate-dichromate methods of aldehyde fixation. The principal neurons are multipolar and mostly mononucleated. They measure between 10 and 50 microns in their average somal diameters. The organelles of the perikaryon are arranged in perinuclear, intermediate and peripheral zones. Unusual organelles consisting of stacks of closely apposed paired membranes, with or without dense bodies studded on their surfaces, are encountered. Nuclear eccentricity is a regular feature of the neuron and the nuclear membrane shows a varying degree of invagination. All parts of the neurons are surrounded by satellite or Schwann cells though dendritic surfaces in direct contact with the basal lamina associated with the satellite cells are not uncommonly seen. Features peculiar to dendrites have been described. Structures resembling dendritic growth cones are present in abundance. Most synapses are axodendritic; axosomatic synapses are much less frequently encountered. While most synapses are of the simple type, complex types are also present. Desmosome-like junctional complexes exist between dendrites, dendrites and somata and axons and dendrites. Differences between Schwann cells of myelinated axons and those of myelinated axons and satellite cells have been noted. In addition to an abundance of macrophages, other connective tissue cells such as mast cells, fibroblasts and plasma cells are also present. Degenerative profiles observed include neuronal cell bodies and cell processes, especially dendrites. They are phagocytosed by the satellite cells and macrophages. The presence of degenerative profiles, chromatolytic neurons and structures resembling dendritic growth cones in the normal stellate ganglion has been discussed.

Animals↗
PubMedDate not supplied

Spread of injectate during C6 stellate ganglion block and fascial arrangement in the prevertebral region: an experimental study using donated cadavers.

BACKGROUND AND OBJECTIVES: The precise fascial space through which the injectate spreads during stellate ganglion block (SGB) remains unclear. Recent studies using magnetic resonance imaging or computed tomography have suggested that the injectate is deposited around and/or within the longus colli muscle during SGB. However, a fascial space, close to the longus colli, is the most likely route of spread. We identified the prevertebral interlaminal space (PVILS), situated between the anterior and posterior laminae of the prevertebral layer of the fascia, as an important route for the spread of the injectate and as a potential pathway to the ganglion. The danger of downward spread of deep infections through this space has previously been recognized. METHODS AND RESULTS: Using the 6th cervical vertebra paratracheal approach technique, we performed experimental SGB with 10 mL latex on donated cadavers. Spreading of latex into the PVILS was observed in 45 of 52 (86.5%) cadavers that had been fixed with formaldehyde after death, and 5 of 8 (62.5%) fresh cadavers. In these experiments, the latex usually reached the ganglion via the PVILS (39 of 45 and 5 of 5, respectively). Moreover, after direct injection into the PVILS, latex reached the ganglion in 13 of a further 19 (68.4%) postmortem-fixed donated cadavers. CONCLUSION: These results suggest that the PVILS plays a critical role in the spread of injectate as well as being a potential pathway to the stellate ganglion during SGB.

Autonomic Nerve Block↗
PubMed2000

Immunohistochemical study of the neuropeptides in the stellate ganglion of the water buffalo.

The localization of some neuropeptides including neuropeptide Y (NPY), substance P (SP), calcitonin gene related peptide (CGRP), vasoactive intestinal peptide (VIP), galanin (Gal), methionine enkephalin (M-ENK), tyrosine hydroxylase (TH) immunoreactivity was studied in the stellate ganglion (SG) of water buffalo. NPY, SP, Gal and TH immunoreactivities were present in almost all of the ganglion cells. NPY, SP, Gal, SP, CGRP, VIP and M-ENK immunoreactive nerve fibers were also seen in the SG. The localization and pattern of distribution of these peptides in the water buffalo stellate ganglion were compared with those in stellate ganglia of other mammalian species.

Animals↗
PubMed2000

Physiologic effects of stellate ganglion block: a result of complete ganglion blockade or the vertical spread of local anesthetic?

Traditionally, stellate ganglion blockade has been used for the diagnosis and treatment of upper extremity sympathetic pain. However, this treatment has not been shown to provide adequate sympathetic blockade of the upper extremities. This study demonstrates that a carefully performed upper thoracic sympathetic block with imaging guidance can result in a successful sympathetic blockade of the upper extremities. This study furthermore demonstrates that the occurrence of a Horners syndrome is not a testimony to a successful sympathetic block of the upper extremities.

Adult↗
PubMedDate not supplied

Stellate ganglion block.

A modified low-dose paratracheal approach to stellate ganglion block at the C6 level prevents the possible complications of subarachnoid introduction of large quantities of local anesthetic, brachial plexus block, and toxic reaction to local anesthetics. It is a technically simple procedure with readily identifiable landmarks and can be performed on an outpatient basis with short recovery periods. Successful block can be readily evaluated. It is emphasized that a series of blocks is required to "disorganize" the reflex activity triggered in the internuncial pools of the spinal cord as well as in the sympathetic ganglia themselves.

Autonomic Nerve Block↗
PubMed1997

Stimulation of left stellate ganglion prolongs Q-T interval in patients with palmar hyperhidrosis.

With the advent of transthoracic video-assisted endoscopic electrocautery of the second and the third sympathetic ganglia for the treatment of palmar hyperhidrosis, it is possible to approach the stellate ganglia with ease. To see whether stimulation of stellate ganglia in humans is similar to the case in dogs, we stimulated the sympathetic ganglia in 18 palmar hyperhidrosis patients with a coagulation power of 5 W at a frequency of three times every 2 s. We found that left stellate stimulation prolongs the Q-T interval and increases the heart rate, whereas right stellate stimulation affects the Q-T interval and heart rate insignificantly, just like the case in dogs in which the left stellate ganglion predominates the right one in determining the Q-T interval. Left stellate stimulation after destruction of the left second and third ganglia also prolongs the Q-T interval, suggesting that the left stellate ganglion is more important in determining the Q-T interval.

Adolescent↗
PubMed1999

Release-depletion and receptor-mediated neuronal internalization of endogenous neurotensin in the stellate ganglion of the cat.

The release and depletion of neurotensin in sympathetic preganglionic axon terminals and internalization in principal ganglion cells were investigated in the cat stellate ganglion by means of combined immunohistochemical staining, image analysis and confocal microscopy. Neurotensin stored in preganglionic boutons was released by 40 or 5 Hz electrical stimulation of preganglionic nerves, being depleted to 7.4 and 19.2% of control levels by continuous stimulation lasting 20 or 160 min (both stimuli delivered 48,000 pulses). Once released, neurotensin was internalized by the principal ganglion cells as evidenced by a ring of bright spot-like granules in the perinuclear region indicating the sites of intracellular neurotensin accumulation. Neurotensin internalization was time-dependent, thus, different content was found when the time between the end of stimulation and start of perfusion was varied. The onset of neurotensin internalization appeared in the first minutes, intracellular accumulation was evident at 20 min, maximal internalization occurred at 120 min and, 24 h later internalized neurotensin content had faded. Internalization was partially blocked by the nonpeptide neurotensin antagonist SR48692. These data provide evidence of presynaptic neurotensin release and depletion by electrical stimulation with varied frequencies. They also provide evidence for in situ receptor-mediated internalization of endogenously released neurotensin, raising the possibility that internalization may represent, in addition to some kind of turnover dynamics, an important part of the mechanisms of neuropeptide signaling.

Animals↗
PubMed1984

The action of cholinergic agonists on the squid stellate ganglion giant synapse.

Although the giant synapse in the squid stellate ganglion has served as a model in the understanding of the ionic and electrical changes that occur during the release of transmitter from nerve terminals, little is known about the pharmacology of this synapse or the identity of its neurotransmitter. In the present study, the suggestion that acetylcholine (ACh) is the excitatory transmitter at this synapse was tested by exploring the actions of cholinergic agents on the pre- and postsynaptic giant axons and on the excitatory postsynaptic potential (EPSP). A novel arterial perfusion technique that circumvents the diffusion barrier from the bathing medium to the synapse has been used to demonstrate a depolarizing action of ACh and its agonist carbachol on the post- but not the presynaptic axon. The cholinergic receptors are distinct from receptors activated by amino acids, such as glutamate, have a reversal potential of about -48 mV, are anion-permeable, and desensitize without blocking the EPSP. It is concluded that these receptors are involved in an inhibitory input onto the postsynaptic giant axon and, therefore, that ACh is most probably not the transmitter at the squid giant synapse.

Acetylcholine↗
PubMed1994

[Circulatory effects of stellate ganglion block in idiopathic facial palsy].

The circulatory effects of stellate ganglion block (SGB) on the blood flow through the common carotid artery were determined in 35 patients in acute phase of idiopathic facial palsy (Bell's palsy). SGB was performed by para-tracheal approach with 8 ml of 1% mepivacaine. The blood flow was measured with an ultrasonic blood flowmeter before and 30 minutes after SGB at both sides of the common carotid artery in 20 cases. Measurement was performed continuously for 90 minutes on the palsy side in the other 15 patients. Before SGB, there were no significant differences between the blood flow of the palsy side and the intact side. Thirty minutes after SGB, the blood flow markedly increased to 169.4 +/- 6.2% on the performed side with no change on the non-performed side in 20 cases. In the other 15 patients, the blood flow increased significantly 5 minutes after SGB and reached its peak of 179.7 +/- 11.1% at 20 minutes later. This increase continued for 75 minutes after SGB. It is well known that impaired microcirculation in the facial nerve has an important role in the pathophysiology of Bell's palsy. In view of the fact that the nutrient arteries for the facial nerve are the peripheral branches of the external carotid artery, we believe that SGB which causes significant increase in the blood flow through the common carotid artery is an effective treatment in Bell's palsy.

Adolescent↗
PubMed1983

The treatment of upper extremity reflex sympathetic dystrophy with prolonged continuous stellate ganglion blockade.

Twenty-nine consecutively treated patients over a 5-year period with upper extremity reflex sympathetic dystrophy were admitted to Massachusetts General Hospital for prolonged continuous stellate ganglion blockade. Diagnosis was based on the presence of pain, decreased joint motion, trophic changes, and vasomotor disturbances. Selection for blockade was made on the failure to improve with outpatient physical therapy, tranquilizers, and mild analgesics. Treatment consisted of indwelling-catheter injections of bupivacaine hydrochloride every eight hours to the stellate ganglion for an average of 7 days, supplemented with vigorous physical therapy. Improvement during treatment was documented in all but two patients with regard to pain and decreased joint motion and in two-thirds with regard to trophic and vasomotor changes. Long-term follow-up demonstrated a relapse rate of 25%, but marked improvement persisted in the rest and normal status was attained in four of 26 patients at an average of 3 years later.

Adult↗