Stellate ganglion block—therapy for cerebral vascular accidents
Editor—Using anterior paratracheal stellate ganglion blocks (APSGB), Gupta and colleagues1 found that it ‘... decreases cerebral vascular tone without affecting the capacity of cerebral blood vessels to react to the changes in carbon dioxide or to autoregulate’. And, proposed that these results suggested that APSGB ‘... may have a therapeutic role in patients where cerebral insufficiency can be attributed to cerebral vasospasm’. This is not new. On the other hand, their view that further studies of the role of APSGB ‘in preventing or treating cerebral vasospasm in subarachnoid haemorrhage are required’ is valid.In 1936, Leriche and Fontaine2 first called attention to the fact that stellate ganglion block (SGB) caused a ‘striking regression of symptoms in two cases of postoperative hemiplegia’. Since then, numerous authors2–16 have emphasized the usefulness of SGB to reduce the vascular spasm associated with cerebral thrombosis and embolism. Most of them advise against its immediate use in cerebral haemorrhage because of the theoretical possibility that it could increase the area of haemorrhage. However, in 1946, Risteen and Volpitto5 noted that patients with fresh cerebral haemorrhages, immediately upon entrance to the hospital, received SGB without any apparent harm resulting from the block.
In all probability, Gupta and colleagues, and others, are unaware that APSGB was first documented over a half century ago (1953) and indicated for: ‘Relief of vasospastic diseases of the arm, brain, and lungs’.17 Subsequently, it became the prevalent technique for administering a SGB. From 1947 to 1955, more than 2000 APSGB were administered for its numerous indications including cerebral vascular accidents ‘without any serious complications’.18 In 1954, a monograph (280 pages) was published encompassing the entire scope of SGB.19 It stated: ‘At the Mason Clinic, we have treated (with APSGB) 26 patients with cerebrovascular accidents within twenty-four hours after their occurrence. No definite diagnosis was established other than the fact that gross blood (or blood cells) was not present in the spinal fluid. Four of these cases showed miraculous improvement and four showed moderate improvement immediately after the block. Eighteen of the patients showed no improvement.’ Furthermore, perhaps of interest is that: ‘Twenty-nine patients, who had cerebrovascular accidents six months to one and one-half years prior to the time we saw them, have been treated (with APSGB) by us. Twenty-one of these cases showed no improvement. Eight showed improvement mentally and in their ability to use remaining muscle power, but in no instance was the extent of paralysis markedly improved’.4
To conclude, the final statement by Gupta and colleagues regarding ‘Further studies ...’ is appropriate and a challenge. The diagnosis of the aetiology of the cerebral vascular accident may be difficult to establish because the greater number of these patients are unable to talk, thus a personal history and consent is unobtainable. And, a history from relatives may be unreliable, and their consent difficult to obtain. Nevertheless, depriving a patient of the possibility of immediate improvement or of shortening the course of the hemiplegia is serious, as a lack of positive results, in all probability, will not affect the patient's future in any way.
D. C. Moore
Seattle, WA, USA
E-mail: daniel.moore{at}vmmc.org
Editor—We thank Dr D.C. Moore for his interest in our study. He has also provided very useful additional information regarding the use of SGB in neurological disorders in the past; many of the references given in his letter are unlikely to be available on modern on-line searches, and therefore, this letter will serve as a useful source of this information.
I must add that our study, in healthy volunteers, attempted to provide a physiological explanation for the possible clinical applications of SGB. I also agree with Dr Moore that more work is required to realize the full potential of this block in neurological disorders.
Nottingham, UK
E-mail: Ravi.mahajan{at}nottingham.ac.uk
References
1 Gupta 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; 95:669–73
2 Leriche R and Fontaine R. De l'infiltration stellaire dans les embolies cérébrales dans les spasmes vasculaire postopératoires de l'encephale et chez les hémiplégiques. Rev Chir 1936; 74:755–8
3 Mackey WA and Scott LDW. Treatment of apoplexy by infiltration of the stellate ganglion with Novocain. Br Med J 1938; 2:1–4
4 Volpitto PP and Risteen WA. The use of stellate ganglion block in cerebral vascular occlusions. Anesthesiology 1943; 4:403–8[CrossRef]
5 Risteen WA and Volpitto PP. Role of stellate ganglion block in certain neurologic disorders. South Med J 1946; 39:431–5
6 Merritt HH. Fundamentals of Clinical Neurology 1947.Blakiston Philadelphia
7 Gilbert NC and de Takats G. Emergency treatment of apoplexy. JAMA 1948; 136:659–65
8 Naffziger HC and Adams JE. Role of stellate block in various intracranial pathologic states. Arch Surg 1950; 61:286–93
9 Ruben JE. Results of stellate ganglion block therapy for cerebrovascular accident. J Philadelphia Gen Hosp 1950; 1:110–15
10 Amyes EW and Perry SM. Stellate ganglion block in the treatment of acute cerebral thrombosis and embolism. JAMA 1950; 142:15–20
11 Searles PW and Nowill WK. Cerebral vascular accidents; treatment by stellate ganglion blocks. South Med J 1950; 43:229–34[Medline]
12 Nosik WA. Stellate ganglion block in cerebrovascular accidents. Ann Intern Med 1951; 35:409–16
13 Sussman I, Lempke R, Wallace R. Stellate ganglion block in cerebral thrombosis and embolism: a preliminary report. Am Pract 1951; 2:217–20
14 Adams JE. Editorial. Stellate ganglion block. Surg Gynecol Obstet 1951; 93:369–71[Web of Science]
15 Leriche R. Treatment of embolism and thrombosis of the cerebral vessels. Br Med J 1952; 1:231–5
16 Gurdjian ES and Webster JE. Stroke resulting from internal carotid artery thrombosis in the neck. JAMA 1953; 151:541–5[Web of Science][Medline]
17 Regional Block Moore DC. 1953; 1st Edn IL Springfield93 Charles C. Thomas
18 Moore DC and Bridenbaugh LD. The anterior approach to the stellate ganglion: use without a serious complication in two thousand cases. JAMA 1956; 160:158–62
19 Moore DC. Stellate Ganglion Block 1954.IL Springfield Charles C. Thomas
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