Abnormal stress responses in patients with diseases affecting the sympathetic nervous system

Patients who lack baroreceptors have exaggerated blood pressure responses to stress. They have episodes of hypertension and hypotension that cause headaches and dizziness.

Patients with diseases of the sympathetic nervous system illustrate that everyday occurrences such as a change in posture or ambient temperature are stresses requiring a marked change in sympathetic nervous activity. Both physical and psychological stresses elicit large initial sympathetic neuronal responses that are subsequently damped by feedback inhibition from structures such as the baroreceptors. Damage to part of these feedback loops leads to exaggerated pressor responses to stress.

Ziegler MG, Ruiz-Ramon P, Shapiro MH.

Psychosom Med. 1993 Jul-Aug;55(4):339-46

abnormality of sympathetic function due to post-sympathectomy denervation

O'Hehir R, Esler M, Jennings G, Leonard P, Little P, Johns J, Panetta F.

The traditional biochemical tests of sympathetic nervous system function used in clinical diagnosis (urine and plasma catecholamine measurements) are indices of "overall" sympathetic nervous activity, and incapable of detecting localised changes in sympathetic tone confined to individual organs. Recently developed radiotracer methods, which enable the pattern of sympathetic nervous dysfunction in disease states to be delineated, were used to detect abnormalities in regional sympathetic nervous system activity in two patients presenting problems in management. In one, the abnormality of sympathetic function was iatrogenic, a post-sympathectomy denervation of the lower regions of the body, associated with incapacitating postural hypotension. In the other, unexplained persistent sinus tachycardia proved to be due to an increase in sympathetic nervous tone restricted to the innervation of the heart. Knowledge of the underlying sympathetic nervous pathophysiology in these patients influenced the choice of drugs subsequently used in their treatment.

Two patients with abnormalities of regional sympathetic nervous tone

Aust N Z J Med. 1984 Dec;14(6):855-9

The autonomic nervous system and cardiac arrhythmias

Disturbed autonomic nervous 'balance' of the sympathetic nervous and vagal outflows to the heart potentiates the experimental development of ventricular arrhythmias in laboratory animals. For some time the best evidence for the occurrence of a similar phenomenon in humans was provided by the long QT interval syndrome, sufferers of which are very prone to develop serious ventricular arrhythmias and in whom evidence exists of abnormal anatomy and function of the cardiac sympathetic nerves. Recently the case for disturbed autonomic function causing clinical arrhythmias has become more broadly based. Reduced baroreflex sensitivity after myocardial infarction, and low heart rate variability, both of which rest largely on vagal underactivity, have been shown to be associated with substantially increased risk of subsequent sudden death.
Esler M.
Baker Medical Research Institute, Prahran, Australia.
Clin Auton Res. 1992 Apr;2(2):133-5.

No sensation of 'thrill' on the sympathtectomized side of the body

Sweet has reported the case of a very intelligent patient, the dean of a graduate school, who after a unilateral sympathectomy to treat his upper limb hyperhydrosis, found that his previous and customary sensation of shivering while listening to a stirring passage of music
occurred in only one side and he could not be thrilled in the sympathectomized half of his body. These cases were interesting because emotions are usually experienced in a rather diffuse 
and bilateral fashion unless innervation has been specifically interrupted. 

Physical Control of the Mind: Toward a Psychocivilized Society
By José Manuel Rodríguez Delgado
Published by Harper & Row, 1969
p. 133-134

Central nervous system activation following peripheral chemical sympathectomy

Callahan TA, Moynihan JA, Piekut DT.

Brain Behav Immun. 1998 Sep;12(3):230-41.

Many studies have demonstrated that ablation of the sympathetic nervous system (SNS) alters subsequent immune responses. Researchers have presumed that the altered immune responses are predominantly the result of the peripheral phenomenon of denervation. We, however, hypothesized that chemicalsympathectomy will signal and activate the central nervous system (CNS).

Activation of the CNS was determined by immunocytochemical visualization of Fos protein in brains from male C57BL/6 mice at 8, 24, and 48 h following denervation. A dramatic induction of Fos protein was found in the paraventricular nucleus (PVN) of the hypothalamus and other specific brain regions at 8 and 24 h compared to vehicle control mice. Dual-antigen labeling demonstrates that corticotrophin releasing factor (CRF)-containing neurons in the PVN are activated by chemical sympathectomy; however, neurons containing neurotransmitters which may modulate CRF neurons, such as vasopressin, tyrosine hydroxylase, and adrenocorticotropin, do not coexpress Fos. Our findings suggest an involvement of the CNS in sympathectomy-induced alterations of immunity.

norepinephrine could not be synthesized and/or accumulated in the heart following bilateral cervical sympathectomy

After bilateral cervical sympathectomy, the norepinephrine content show a rapid decrease from 4 days to 7 days and a slow decrease within the following 14 days. No tendency of recovery was apparent in the heart for 50 days following the operation, the norepinephrine content remaining almost at an equal level.
It was postulated that norepinephrine could not be synthesized and/or accumulated in the heart following bilateral cervical sympathectomy, but that cardiac muscle might synthesize dopamine for itself.

Japanese circulation journal

Vol.29, No.1(19650120) pp. 11-15

KIMATA SHIN-ICHI ¹

¹The Third Department of Internal Medicine, Faculty of Medicine, University of Tokyo

sympathetic denervation with minor arrhythmias

Based on the above findings, we suggest myocardial sympathetic denervation with lowered initial H/M (heart-to-mediastinum count ratios) will develop following surgical sympathectomy at upper cervical ganglia, which will accompanied by compensated uptake-1 system on presynaptic nerve endings of postganglionic neuronal cells, demonstrated by lowered MWO, and preserved homodynamic function and ECG changes except for minor arrhythmias.

Hemodynamic and ECG changes associated with deteriorations in 123I-MIBG adrenergic myocardial imaging following surgical sympathectomy in SD rats

Cheng-Yi Cheng¹, Nien-Hsien Liou², Chieh-Ling Kao², An-Sui Yang³, Lei-Hang Shen³, Ging-Cheng Perng¹ and Wen-Sheng Huang¹

¹ Department of Nuclear Medicine, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan; ; ² Institute of Biology and Anatomy, National Defense Medical Center, Taipei, Taiwan; ; ³ Institute of Nuclear Energy Research, Taipei, Taiwan

http://jnumedmtg.snmjournals.org/cgi/content/meeting_abstract/48/MeetingAbstracts_2/226P-b

sympathectomy on muscle fibre composition

We have previously reported functional and histological studies in five beagle dogs with unilateral lumbar sympathectomy. Three months later, fatiguability in the gracilis muscles was increased on the denervated sides, and this was associated with an increase in the relative distribution of FT fibres. Biochemical studies now show that these changes were associated with an increase in cytosolic protein without change in DNA content; this is consistent with an increase in cell size. There was a reduction in the proportion of slow myosin light chain isoforms from 50 ± 7 to 34 ± 6%. Noradrenaline levels were increased on the denervated sides but this may reflect greater vascularity. Calcium content did not correlate with fibre type but there was a positive relation with both noradrenaline content (r= 0·73; P<0 class="i">r= 0·84; P<0 span=""> It is concluded that sympathectomy induces several biochemical changes in skeletal muscle which constitute a change and increase in fast myosin light chain synthesis and a corresponding fibre type transformation.

Correspondence to ¹ Department of Clinical Physiology, Karolinska Hospital, S-104 01 Stockholm, SwedenReceived 24 August 1987; accepted 26 October 1987
http://www3.interscience.wiley.com/journal/119466197/abstract

irreversible deterioration in cardiac function

The concept of posterior nerve root section was resurrected 10 years later, when Danielopolu (Director of the Second Medical Clinic at the University of Bucharest) criticized the Jonnesco-type sympathectomy on the grounds that it produced an irreversible deterioration in cardiac function. He therefore directed his surgical colleague, Hristide, to cut the posterior roots of the upper thoracic spinal nerves which divided only sensory fibres.
Danielopolou later declared cervicothoracic sympathectomy to be disastrous, from the therapeutic point of view, and concluded that removal of the stellate ganglion for angina was incompatible with life.

Landmarks in Cardiac Surgery

By Stephen Westaby, Cecil Bosher
Published by Informa Health Care, 1997

Phenol application Asynchronous wall motion Impaired nerve conduction Contraction disparity

EFFECT OF LOCAL CARDIAC SYMPATHECTOMY ON REGIONAL MYOCARDIAL CONTRACTION

KOMATSU EIICHI YAMAGUCHI ICHIRO MIYAZAWA KOZUI

These observations indicated that the abnormal pressure-length loop was derived from the delayed contraction in the phenol treated region.
Japanese circulation journal

Vol.52, No.7(19880720) pp. 617-623

Sympathectomy induces novel purinergic sensitivity

Twenty eight percent of the spontaneously active afferent fibres from sciatic nerves in the sympathectomyzed rats responded to ATP, either with an increase or with a decrease in spontaneous firing. However, none of the fibres from the sciatic nerves in the intact rats was activated by ATP.

Sympathectomy induces novel purinergic sensitivity in A afferents from sciatic nerve.
It is thought that this novel purinergic sensitivity may contribute to neuropathic paraesthesia and pain.
CHEN YONG, ZHANG YI-HONG, BIE BI-HUA, ZHAO ZHI-QI
Shanghai Institute of Physiology, Chinese Academy of Sciences
Acta Pharmacol Sin, 2000 Nov; 21 (11):1002-1004

Pulmonary function abnormalities following upper dorsal sympathectomy for hyperhidrosis

Spirometry 3 months after surgery showed a significant decrease in the forced vital capacity (−5.2%), the forced expiratory volume in the first second (−6.1%), and the forced expiratory flow between 25% and 75% of vital capacity (−5.1%). Whereas methacholine challenge testing before surgery was positive in 3 subjects (2 of whom were asthmatic), it was positive in 6 patients after the procedure; differences were not statistically significant. After 12 months, forced vital capacity started recovering, and forced expiratory volume in the first second and forced expiratory flow rate 25% to 75% showed a sustained and significant reduction (−2.8% and −11.2%, respectively.

The Journal of Thoracic and Cardiovascular Surgery , Volume 129 , Issue 6 , Pages 1379 - 1382

M . Ponce González , G . Julià Serdà , N . Santana Rodríguez , P . Rodríguez Suárez , G . Pérez Peñate , J . Freixinet Gilart , P . Cabrera Navarro

Sympathectomy on the Cardiac Neurovegetative Equilibrium

Since the first attempts of T. Jonnesco’ to treat angina pectoris by
means of cervico-thoracic sympathectomy, many surgeons have applied
similar techniques with satisfactory results in the majority of instances.2
Nearly without exception, the operations were performed with the de-
clared purpose to sever sensory, pain-conveying, afferent nervous path-
ways, and without realization of the fact that (except in the case of
exclusive section of the posterior roots), the norepinephrine-discharging,
pain-producing efferent sympathetic fibers3 were, likewise, interrupted.
In animal experiments, it has been shown that electrical stimulation
of the cardiac sympathetic nerves is followed by an accumulation of
catecholamines,4.s especially of norepinephrine,’ in the myocardium,
whereas the cardiac catecholamine stores are largely depleted by sym- 
pathectomy.7” 

The prolongation of the isometric (tension) period (TP) of the left ventricle which
occurred in the majority (72 per cent) of all cases after unilateral or bilateral trans-
thoracic sympathectomy (without or with unilateral or bilateral transthoracic splanch-
nicotomy) indicates a diminution of inotropic cardiac action. It can be assumed to
correspond to the cholinergic (vagal) preponderance which results from a partial or
complete sympathetic denervation of the heart. Reduction of the pulse pressure oc-
curred in 56 per cent of the cases, probably due to the same mechanism. The be-
havior of the heart rate was too irregular to permit any conclusions. Apparently, the
Inotropic mechanisms of the heart are more sensitive to sympathetic denervation than
the chronotropic ones. 

The seemingly paradoxical shortening of TP which was persistently maintained,
e.g., in the case of patient 16 over a period of more than five months, is possibly to
be explained as a manifestation of Cannon’s “law of denervation” according to which
the catecholamine sensitivity of sympathetically denervated structures Is greatly aug-
mented, and which has more recently been confirmed also in instances of functional
sympathetic “denervation” (catecholamine deprivation of cardiovascular tissues)
through gangllomc blockade” or rauwolfia drugs.’6 This would mean in the present
cases that their partly or wholly sympathectomized hearts had become oversensitive to
whatever active catecholamines (norepinephrine, eplnephrine) may have reached them
either from remaining sympathetic fibres or through the blood stream. Individual
differences in relative reactivity to two mutually antagonistic factors ([a] absolute
loss of catecholammes, and Eb] exaggerated catecholamine sensitivity, caused by [a 1),
combined with the individual magnitude of absolute cardiac cholinergic activity, may
account for the prevalence of either negative or positive Inotropic cardiac reactions
to sympathectomy.

DOI 10.1378/chest.38.4.423
1960;38;423-428 Chest

W. RAAB, E. KUX and H. MARCHET

Baroreflex Control of Heart Rate during Cardiac Sympathectomy

The results suggest that cardiac sympathectomy induced by epidural anesthesia can suppress partially baroreceptor function by interrupting sympathetic efferent fibers innervating the heart during high levels of epidural anesthesia, but that lumbar sympathectomy during epidural anesthesia is unlikely to affect baroreceptor activity.
Anesth Analg 1983; 62:815-820
http://www.anesthesia-analgesia.org/cgi/content/abstract/62/9/815

Ventricular Ectopic Rhythms and Ventricular Fibrillation Following Cardiac Sympathectomy

A. Sidney Harris, Antonio Estandia and Rex F. Tillotson
From the Department of Physiology, Baylor University College of Medicine, Huston, Texas
Am J Physiol 165: 505-512, 1951;