In patients with acute ischemic stroke, reversibility of the neurologic deficits depends on the depth and dura tion of the ischemic insult. The rapid elevation of cere bral blood flow (CBF) above ischemic thresholds may minimize or prevent infarction. Reduction of blood vis cosity has been shown to augment CBF and improve cerebral neuronal activity after stroke. Hypervolemic hemodilution decreases hematocrit, increases blood volume, augments cardiac output, and, in randomized clinical trials, improves the long-term outcome in acute ischemic stroke. Similarly, administration of drugs that decrease plasma fibrinogen and increase erythrocyte flexibility reportedly causes a decrease in the incidence of recurrent ischemia after an initial transient ischemic attack. Thus, the pharmacologic manipulation of blood viscosity appears to be effective in managing patients with acute ischemic stroke.
Get full access to this article
View all access options for this article.
References
1.
Jones TH, Morawetz RB, Crowell RM, et al. Thresholds of focal cerebral ischemia in awake monkeys. J Neurosurg1981;54:773-782
Polyzoidis KS , Wood JHCardiac and rheologic aspects of cerebral blood flow. In: Hurst WJ, ed. Clinical essays on the heart. Vol. 3. New York: McGraw-Hill, 1984:105-119
4.
Diaz FG, Mastri AR, Ausman JI, Chou SNAcute cerebral revascularization after regional cerebral ischemia in the dog: part II, clinicopathological correlation. J Neurosurg1979;51: 644-653
5.
Dujovny M., Osgood CP, Barrionuevo PJ, et al. Middle cerebral artery microneurosurgical embolectomy. Surgery1976; 80:336-339
6.
Rhodes RS, Spetzler RF, Roski RAImproved neurologic function after cerebral vascular accident with extracranialintracranial arterial bypass. Surgery1981;90:433-438
7.
Wood JH, Polyzoidis KS, Epstein CM, et al. Quantitative EEG alterations after isovolemic-hemodilutional augmentation of cerebral perfusion in stroke patients. Neurology1984; 34:764-768
8.
Wood JH, Polyzoidis KS, Kee DB, et al. Augmentation of cerebral blood flow induced by hemodilution in stroke patients after superficial temporal-middle cerebral arterial bypass operation. Neurosurgery1984;15:535-539
9.
Wood JH, Polyzoidis KS, Kee DB, et al. Adjunct hemodilutional therapy after STA-MCA bypass surgery: postoperative augmentation of cerebral blood flow in stroke patients. In: Spetzler RF, Carter LP, Selman WR, Martin NA, eds. Cerebral revascularization for stroke. New York: Thieme-Stratton; 1985:154-159
10.
Kee DB, Wood JHExperimental hemodynamic and rheologic alterations of blood flow through carotid stenosis following hemodilution. Neurology1986;36(suppl 1):230
11.
Kee DB, Wood JHExperimental augmentation of carotid blood flow through graded stenoses after hemodilution. Presented at the Annual Meeting of American Association of Neurological Surgeons, Denver, CO, April 13-17, 1986
12.
Dintenfass L.Blood microrheology-viscosity factors in blood flow, ischemia and thrombosis. New York: Appleton-Century-Crofts, 1971:5-129, 266-355
13.
Merrill EWRheology of blood. Physiol Rev1969 ;49:863-888
14.
Kee DB, Wood JHRheology of cerebral circulation. Neurosurgery1984;15:125-131
15.
Schmid-Schonbein H.Factors promoting and preventing the fluidity of blood. In: Effros RN, Schmid-Schonbein H, Ditzel J, eds. Microcirculation. New York: Academic Press, 1981: 249-266
16.
Sakuta S.Blood filterability in cerebral vascular disorders, with special reference to erythrocyte deformability and ATP content. Stroke1981;12:824-827
17.
Tohgi H., Uchiyama S., Ogawa M., et al. The role of blood constituents in the pathogenesis of cerebral infarction. Acta Neurol Scand1979;72(suppl):616-617
18.
Chien S., Vsami S., Taylor HM, et al. Effects of hematocrit and plasma proteins on human blood rheology at low shear rates. J Appl Physiol1966;21:81-87
19.
Gaehtgens P. , Kreutz F., Albrecht KHFahraeus effect and cell screening during tube flow of human blood: II. effect of dextran-induced aggregation. Biorheology1978;15:155-161
20.
Downs A., Litt M., Kron RELow shear rate viscosity of fresh blood. Biorheology1980;17:25-35
21.
Yepsen G., Boutin D., Litt M., Kron RERheological modelling of fresh blood from transient pressure measurements . Biorheology1981;18:475-484
22.
McHenry LD, West JW, Cooper ES, et al. Cerebral autoregulation in man. Stroke1974;5:695-706
23.
Yatsu FMAcute medical therapy of strokes. Stroke1982 ;13:524-526
24.
Grotta J., Ackerman R., Correia J., et al. Whole blood viscosity parameters in cerebral blood flow. Stroke1982;13:296-301
25.
Thomas DJ, Duboulay GH, Marshall J., et al. Effect of haematocrit on cerebral blood flow in man. Lancet1977;2:941-943
26.
Kee DB, Wood JHRheology of the cerebral circulation. Neurosurgery1984;15:125-131
27.
Ott EO, Ladurner G., Lechner H.Relationship between disturbed rheological properties and cerebral hemodynamics in recent cerebral infarction. Prog Biochem Pharmacol1977;13:349-352
28.
Hasegawa T. , Ravens JR, Toole JFPrecapillary arteriovenous anastomoses: "thoroughfare channels" in the brain. Arch Neurol1967;16:217-229
29.
Fahraeus R. , Lindqvist T.The viscosity of blood in narrow capillary tubes. Am J Physiol1931;96:562-568
30.
Dintenfass L.Inversion of the Fahraeus-Lindqvist phenomenon in blood flow through capillaries of diminishing radius. Nature1967;215:1099-1100
31.
Barbee JH, Cokelet GR The Fahraeus effect. Microvasc Res1971;3:6-16
32.
Gaehtgens P. , Albrecht KH, Kreutz F.Fahraeus effect on cell screening during tube flow of human blood. I. effect of variation of flow rate. Biorheology1978;15:147-154
33.
Whitmore RLRheology of the circulation. Oxford: Pergamon Press, 1967:37-46, 109-133
34.
Lammertsma AA, Brooks DJ, Beaney RP, et al. In vivo measurement of cerebral haematocrit using position emission tomography. J Cereb Blood Flow Metab1984;4:317-322
35.
WoodJH, Kee DB. Clinical rheology of stroke and hemodilution. In: Barnett HJM, Mohr JP, Stein BM, Yatsu FM, eds. Stroke: pathophysiology, diagnosis, and management. New York: Churchill-Livingstone , 1986:97-108
36.
Wood JH, Kee DBHemorheology of the cerebral circulation in stroke. Stroke1985;16:765-772
37.
Selman WR, Spetzler RFTherapeutics for focal cerebral ischemia. Neurosurgery1980;6:446-452,
Kiyohara Y. , Fujishima M., Ishitsuka T., et al. Effects of hematocrit on brain metabolism in experimentally induced cerebral ischemia in spontaneously hypertensive rats. Stroke1985;16;835-840
40.
Wood JH, Simeone FA, Fink EA, Golden MAHypervolemic hemodilution in experimental focal cerebral ischemia: elevation of cardiac output, regional cortical blood flow, and ICP after intravascular volume expansion with low molecular weight dextran. J Neurosurg1983;59:500-509
41.
Wood JH, Simeone FA, Fink EA, Golden MACorrelative aspects of hypervolemic hemodilution with low-molecular-weight dextran after experimental cerebral arterial occlusion. Neurology1984;34:24-34
42.
Wood JH, Simeone FA, Snyder LL, et al. Hemodilutional and nonhemodilutional hyperyolemia in treatment of focal cerebral ischemia. J Cereb Blood Flow Metab1981;1(suppl 1):S178-S179
43.
WoodJH, Simeone FA, Kron RE, Litt M.Rheological aspects of experimental hypervolemic hemodilution with low-molecular-weight dextran: relations of cortical blood flow, cardiac output and intracranial pressure to fresh blood viscosity and plasma volume. Neurosurgery1982;11:739-753
44.
Wood JH, Simeone FA, Kron RE, et al. Relationship of cortical blood flow and cardiovascular responses to alterations in fresh blood viscosity as determined by capillary step-response viscometry. J Cereb Blood Flow Metab1981; 1(suppl 1):S233-5234
45.
Wood JH, Simeone FA, Kron RE, Snyder LLExperimental hypervolemic hemodilution: physiological correlations of cortical blood flow, cardiac output and intercranial pressure with fresh blood viscosity and plasma volume. Neurosurgery1984;14:709-723
46.
Hint H.The pharmacology of dextran and the physiological background for the use of Rheomacrodex and Macrodex. Acta Anaesth Belg1968;19:119-138
47.
Sunder-Plassman L., Klovedorn WP, Holper K., et al. The physiological significance of acutely induced hemodilution. In: Nitzel J , Lewis DH, eds. Sixth European conference of microcirculation. Basel: Karger, 1970:23-28
48.
Czer Lsc, Shoemaker WCOptimal hematocrit value in critically ill postoperative patients . Surg Gynecol Obstet1978;142:363-368
49.
Wood JH, Simeone FA, Snyder LLCortical oxygen transport during hypervolemic hemodilutional therapy for focal cerebral ischemia (abstract). Neurosurgery1982;10:781
50.
Fein JMComment on [45]. Neurosurgery1984 ;14:722-723
51.
Kusunoki M. , Kimura K., Nakamura M., et al. Effects of hematocrit variations on cerebral blood flow and oxygen transport in ischemic cerebrovascular disease . J Cereb Blood Flow Metab1981;1:413-417
52.
Wade Jph.Transport of oxygen to the brain in patients with elevated haematocrit values before and after venesection. Brain1983;106:513-523
53.
Wood JH, Snyder LL, Simeone FA Failure of intravascular volume expansion without hemodilution to elevate cortical blood flow in region of experimental focal ischemia. J Neurosurg1982;56:80-91
54.
Sundt TM, Walz AG, Sayre GPExperimental cerebral infarction: modification by treatment with hemodiluting, hemo-concentrating, and dehydrating agents. J Neurosurg1967; 26:46-54
55.
Keller TS, McGillicuddy JE, LaBond DA, Kindt G.Volume expansion in focal cerebral ischemia: the effect of cardiac output on local cerebral blood flow. Clin Neurosurg1982;29:40-50
56.
Grotta J., Ostlow P., Fraifeld E., Hartman D.Reduction of fibrinogen and viscosity does not significantly alter ischemic injury. J Cereb Blood Flow Metab1982;3(Suppl 1):S349-S350
57.
Ott EO, Lechner H., Aranibar A.High blood viscosity syndrome in cerebral infarction. Stroke1974;5:330-333
58.
Harrison NJ , Pollock S., Kendell DE, Marshall J.Effect of haematocrit on carotid stenosis and cerebral infarction. Lancet1981;2:114-115
59.
Prats AR, Wood JH, Kron RE, Kron SJRelative influence of hematocrit and plasma fibrinogen as determinants of fresh blood viscosity during hemodilution therapy in stroke patients. Presented at the International Symposium on Cerebral Blood Flow and Metabolism, Lund, Sweden, June 1985
60.
Pollock SS, Harrison Mjg.Red cell deformability is not an independent risk factor in stroke . J Neurol Neurosurg Psychiatry1982;45:369-371
61.
Couch JR, Assanein RSPlatelet aggregation, stroke in transient ischemic attack in middle-aged and elderly patients. Neurology1976;26:888-895
62.
Grotta JC, Pettigrew LC, Allen S., et al. Baseline hemodynamic state and response to hemodilution in patients with acute cerebral ischemia. Stroke1985;16:790-795
63.
Davis DH, Sundt TMRelationship of cerebral blood flow to cardiac output, mean arterial pressure, blood volume and alpha and beta blockade in cats. J Neurosurg1980;52:745-754
64.
Burke AM, Chien S., McMurtry JG, Quest DOEffects of low molecular weight dextran on blood viscosity after craniotomy due to cranial aneurysm. Surg Gynecol Obstet1979;48:9-15
65.
Gilroy J., Barnhart MI, Meyer HSTreatment of acute stroke with dextran 40. JAMA1969;210:293-298
66.
Gottstein U. , Sedlmeyer I., Heiss A.Behandlung der akuten zerebralen Mangeldurchblutung mit niedermolekularem Dextran (treatment of acute cerebral ischemia with low-molecular-weight dextran). Dtsch Med Wochenschr1976; 101:223-227
67.
Heiss WD, Prosenz P., Tschabitshar H., et al. Effect of low molecular weight dextran on total cerebral blood flow and on regional flow within ischemic brain lesions. Eur Neurol1972;8:129-133
68.
Kaste M., Fogelholm R., Waltimo O.Combined dexamethasone and low-molecular-weight dextran in acute brain infarction: double-blind study. Br Med J1972 ; 2: 1409-1410
69.
Matthews WB , Oxbury JM, Grainger Kmr, Greenhall Rcd.A blind controlled trial of dextran 40 in the treatment of ischaemic stroke. Brain1976 ;99:193-206
70.
Spudis EV, de la Torre E., Pikula L.Management of completed strokes with dextran 40: a community hospital failure . Stroke1973;4:895-897
71.
Wood JH, Polyzoidis KS, Epstein CM, et al. Improvements in cerebral blood flow and power spectral EEG after isovolemic hemodilution in stroke patients. J Cereb Blood Flow Metab1983;3(suppl 1):S588-S589
72.
Strand T., Splund K., Eriksson S., et al. A randomized control trial of hemodilution therapy in acute ischemic stroke. Stroke1984;15:980-989
73.
Corry WD, Jackson LJ, Seaman Gvf: The effect of hydroxyethyl starch on the rheological properties of human erythrocyte suspension. Biorheology1981;188:517-529
74.
Ott E., Lechner H.Changes of flow properties of the blood in cerebrovascular disease and medical treatment with pentoxifylline. J Cereb Blood Flow Metab1983;3(suppl 1):S530-S531
75.
Herskovits E., Famulari A., Tamaroff L., et al. Preventative treatment of cerebral transient ischemia: comparative randomized trial of pentoxifylline versus conventional antiaggregants. Eur Neurol1985 ;24:73-81
76.
Wood JH, Fleischer ASObservations during hypervolemic hemodilution of patients with acute focal cerebral ischemia. JAMA1982;248:2999-3004
77.
Pritz MBCardiopulmonary monitoring during graded cervical internal carotid artery occlusion: Physiological results and therapeutic implications. Neurosurgery1980;8:520-524
