Subarachnoid hemorrhage (SAH) following cerebral aneurysm rupture is associated with substantial morbidity and mortality. The ability of SAH to induce vasospasm in large diameter pial arteries has been extensively studied, although the contribution of this phenomenon to patient outcome is unclear. Conversely, little is known regarding the impact of SAH on intracerebral (parenchymal) arterioles, which are critical for regulation of cerebral blood flow. To assess the function of parenchymal arterioles following SAH, measurements of diameter, intracellular Ca2+ ([Ca2+]i) and membrane potential were performed in intact arterioles from unoperated (control), sham-operated and SAH model rats. At physiological intravascular pressure, parenchymal arterioles from SAH animals exhibited significantly elevated [Ca2+]i and enhanced constriction compared with arterioles from control and sham-operated animals. Elevated [Ca2+]i and enhanced tone following SAH were observed in the absence of vascular endothelium and were abolished by the L-type voltage-dependent Ca2+ channel (VDCC) inhibitor nimodipine. Molecular assessment of the L-type VDCC CaV1.2 indicated unchanged mRNA and protein expression in arterioles from SAH animals. Increased CaV1.2 activity following SAH may also reflect enhanced pressure-induced membrane potential depolarization of arteriolar smooth muscle. Membrane potential measurements in arteriolar myocytes using intracellular microelectrodes revealed approximately 7 mV depolarization at 40 mmHg in myocytes from SAH animals. Further, when membrane potential was adjusted to similar values, arteriolar [Ca2+]i and tone were similar between groups. These results demonstrate that greater pressure-dependent membrane potential depolarization results in increased activity of CaV1.2 channels, elevated [Ca2+]i and enhanced constriction of parenchymal arterioles from SAH animals. Thus, impaired regulation of parenchymal arteriolar [Ca2+]i and diameter may restrict cerebral blood flow in SAH patients. Although nimodipine is used clinically to prevent delayed neurological deficits in SAH patients, the use of this drug has been limited by hypotension and treatment options remain inadequate. Therefore, our next objective was to explore strategies to selectively suppress CaV1.2 channels in the cerebral vasculature. To do so, we examined the physiological role of smooth muscle CaV1.2 splice variants containing the alternatively-spliced exon 9* in cerebral artery constriction. Using antisense oligonucleotides, we demonstrate that suppression of exon 9*-containing CaV1.2 splice variants results in substantially reduced cerebral artery constriction to elevated extracellular [K+]. In addition, no further reduction in constriction was observed following suppression of all Cav1.2 splice variants, suggesting that exon 9* splice variants are functionally dominant in cerebral artery constriction. In summary, results shown in this dissertation demonstrate that increased CaV1.2 activity following SAH results in enhanced constriction of parenchymal arterioles. Furthermore, evidence is provided supporting the concept that CaV1.2 splice variants with exon 9* are critical for cerebral artery constriction and may provide a novel target for the prevention of delayed ischemic deficits in SAH patients.

Computed Tomography Coronary Angiography (CTCA)is a technique for imaging coronary arteries with increasing indications in clinical cardiology. AIMS 1.Develop a heart rate (HR) lowering regime for CTCA and to measure its association with image quality. 2.Examine the diagnostic accuracy of 64 slice CTCA (CTCA64) in patients with known coronary artery disease (CAD). 3.Examine the diagnostic accuracy of CTCA64 for assessment of stent restenosis 4.Demonstrate utility of CTCA as an endpoint in assessment of novel diagnostic biomarkers of CAD. METHODS I developed a HR reducing strategy using metoprolol and assessed its effectiveness for improving CTCA64 image quality. The diagnostic value of CTCA in patients with suspected angina was evaluated by comparison with invasive coronary angiography. The diagnostic value of CTCA for quantifying stent restenosis was evaluated by comparison with intravascular ultrasound. The utility of CTCA for evaluating the diagnostic value of B-type natriuretic peptide (BNP) and high sensitivity cardiac troponin I (hs- TnI) was evaluated by blood sampling in patients with suspected angina who subsequently underwent CTCA. RESULTS 1.In 121 patients undergoing CTCA, 75 required rate control. This was achieved (rate ≤60 bpm) in 83% using a systematic regimen of oral and IV metoprolol (n=71) or verapamil (n=4). I demonstrated a significant relation between HR reduction and graded image quality (p<0.001). 2.80 patients underwent CTCA64 and invasive coronary angiography. 724 coronary arterial segments were available for analysis. The sensitivity and specificity of CTCA for significant luminal stenosis was 83.3% (95% CI 67.1-92.5%) and 96.7% (95% CI 95.1-97.9%), respectively, but the positive predictive value was only 63.5% (95% CI 50.4-75.3%). 3.80 patients with 125 stented segments underwent CTCA64 and invasive coronary angiography. Additional intravascular ult rasound (IVUS) examination of stented segments was performed in 48 patients. Using IVUS as the gold-standard for stent restenosis, CTCA and invasive coronary angiography had comparable diagnostic specificities for binary stent restenosis: 82.7% (95% confidence intervals 69.7- 91.84%)and 78.9% (95% confidence intervals 65.3-88.9%), respectively. Sensitivities were lower, particularly the sensitivity of CTCA which was only 11.8% (95% confidence intervals 1.5-36.4%) compared with 58.8% (95% confidence intervals 32.9-81.6%) for invasive coronary angiography. 4. In 93 patients with suspected angina CTCA64 provided a useful endpoint for assessing the diagnostic value of novel circulating biomarkers. BNP levels were higher in the 13 patients shown to have significant (≥50% stenosis) coronary artery disease compared with patients who had unobstructed coronary arteries (18.08pg/ml (IQR 22) vs 9.14pg/ml (IQR 12.62), p=0.024) and increased significantly with exercise, particularly in the group with anatomic coronary artery disease (2.73 ± 5.69 pg/ml vs 1.27±3.29 pg/ml, p=0.16). Conversely I found no association between hs-TnI and the presence of CAD. CONCLUSION Image quality of CTCA64 is enhanced by heart rate reduction below 60 bpm which can be achieved safely by a regimen of oral and intravenous metoprolol. Although CTCA64 is a useful non-invasive method for diagnosis of coronary artery disease, it has a low positive predictive value for identifying severe (≥50%) luminal stenosis which limits its clinical value. Its value for assessment of stent restenosis is even more limited but it finds useful application as an endpoint for diagnostic evaluation of novel biomarkers, allowing confirmation of an association between circulating BNP levels and stable coronary artery disease.

Cardiovascular disease (CVD) affects millions of people worldwide. Many of these people require treatment for their condition, and for roughly a million individuals each year, this treatment includes coronary artery bypass graft (CABG) surgery - a procedure that aims to restore proper blood flow to the arteries of the heart. Although the physical impact of CVD and CABG surgery are well-known, their cognitive impact has not been clearly established. Recent studies suggest that both CVD and CABG surgery may have a detrimental effect on neuropsychological functioning. The first goal of the present study was to cognitively assess patients with severe, chronic CVD to determine the association of heart disease with neuroopsychological functioning. The second goal was to then continue monitoring these patients once they had undergone CABG surgery to establish what cogntive effect this treatment has. CABG surgery has traditionally been performed with the aid of a cardiopulmonary bypass (CPB) machine, but in the past decade, another technique, in which the heart remains beating, has been developed. Some have argued that this beating heart surgery (BHS) may be a superior alternative to the CPB procedure. Consequently, the third goal of the present study was to compare outcomes in patients undergoing these two surgical procedures. The present study had a prospective, double blind design. Patients were randomly assigned to either CPB surgery (CPBS) or BHS. Sixty-three patients were recruited and underwent a comprehensive neuropsychological assessment preoperatively and 6 days, 6 weeks and 30 weeks postoperatively. Despite including a higher risk group than previous comparative studies, there were virtually no differences between the CPBS and BHS groups. When the groups were combined and the sample was examined as a whole, the patients were cognitively impaired even before their surgery. Given that their premorbid abilities were estimated to be in the average range, their pre-surgery deficits were likely to be the result of a long-standing history of CVD. Immediately after surgery (Day 6), the neuropsychological performance of the sample decreased further, but they had significantly improved by Week 6 and this improvement increased further by the Week 30 time-point (with many scores in the average range). This postoperative recovery suggests that the decline these patients exhibit preoperatively may be reversible and that rather than causing cognitive deficits, CABG surgery may ultimately improve both cardiac and cognitive health. Psychologically, patients in the present sample reported the highest level of anxious and depressive symptoms, and the lowest quality of life, pre-surgically, but their psychological health gradually improved over the course of the postoperative period. Compared to other samples, however, the present sample were generally psychologically healthy.

Thesis (Ph. D.)--University of Hong Kong, 2007. / Title proper from title frame. Also available in printed format.

The leading cause of death in patients who survive subarachnoid hemorrhage (SAH) is stroke as a result of cerebral arterial vasospasm1. Such vasospasms involve a vasoactive response, but they remain enigmatic and no clinical treatment has proven effective in prevention or reduction2. Arteries remodel in response to diverse mechanical loads and chemical factors. Following SAH, the surrounding vasculature is exposed to a radically altered chemo-mechanical environment. It is our hypothesis that chemical stimuli associated with the formation of an extravascular blood clot dominates the maladaptive growth and remodeling response early on, thus leading to important structural changes. However, it is not clear which of the many chemical factors are key players in the production of vasospasm. Before an accurate picture of the etiology of vasospasm can be produced, it is imperative to gain a better understanding of the non-pathogenic cerebral vasculature. In particular, the rabbit basilar artery is a well established model for vasospasm. However, surprisingly little is known about the mechanical properties of the rabbit basilar artery. Using an in vitro custom organ culture and mechanical testing device, acute and cultured basilar arteries from male White New Zealand specific pathogen free rabbits underwent cyclic pressurization tests at in vivo conditions and controlled levels of myogenic tone. Sections of basilar arteries were imaged for collagen fiber orientation at 0, 40 and 80 mmHg at in vivo stretch conditions using nonlinear optical microscopy. The nonlinear stress-strain curves provide baseline characteristics for acute and short-term culture basilar arteries. The active and passive testing creates a framework for interpreting the basal tone of arteries in our culture system. Nonlinear optical microscopy second harmonic generation provides unique microstructural information and allows imaging of live, intact arteries while maintaining in vivo geometries and conditions. Collagen fibers were found to be widely distributed about the axial direction in the adventitial layer and narrowly distributed about the circumferential direction in the adventitial layer. The quantified collagen fiber angles within the artery wall further support the development of accurate mathematical models.

Cerebrovascular disease continues to be responsible for significant morbidity and mortality. There is a pressing need to better understand the biomechanics of both intracranial arteries and the extracranial arteries that feed these vessels. Histology and immunohistochemistry were performed on basilar and carotid arteries and elucidated their structural differences. Nonlinear optical microscopy (NLOM) provided collagen fiber orientation and distribution, which offered motivation for a more microstructrually-based model. Biaxial testing was performed on acute basilar and carotid arteries and cultured basilar arteries. We used a validated 2D, four fiber family constitutive relation to model passive biaxial stress-stretch behaviors of basilar and common carotid arteries, and we developed a new relation to model their active biaxial responses. Residual stress information from opening angles and collagen fiber orientation were used to create a 3D fiber distribution constitutive relation. Passive biaxial stress-stretch behavior of basilar arteries was modeled with the 3D fiber distribution constitutive relation and was combined with our new active relation to model the active response of basilar arteries. These data and 2D, four fiber family and active constitutive relation allow the first full comparison of circumferential and axial biomechanical behaviors between a muscular (basilar) and an elastic (carotid) artery from the same species. Our active model describes the responses by both types of vessels to four doses of the vasoconstrictor endothelin-1 (10^-10, 10^-9, 10^-8, 10^-7 M) and predicts levels of smooth muscle activation associated with basal tone under specific in vitro testing conditions. Cultured arteries revealed smooth muscle tone is necessary for vascular remodeling. Our 3D model allowed for the calculation of stress through the wall in passive basilar arteries. These results advance our understanding of the biomechanics of intracranial and extracranial arteries, which is needed to understand better their differential responses to similar perturbations in hemodynamic loading.

Restenosis is one of the major adverse outcomes of Percutaneous Coronary Intervention (PCI). Previous studies have shown conflicting reports for homocysteine as a predictor of restenosis following PCI. The conflicting reports may be due to oxidative factors (stimulation of polymorphonuclear leukocyte [PMNL]-induced reactive oxygen species generation, xanthine- xanthine oxidase, and arachidonic acid metabolism) other than homocysteine which could cause endothelial cell dysfunction leading to restenosis. Malondialdehyde (MDA), a lipid peroxidation product, is a marker for oxidative stress and is related to all oxidative factors. Therefore, it is possible that serum MDA may be a better predictor of restenosis than plasma homocysteine. The purpose of this study is to determine whether or not the pre-procedural serum MDA and plasma homocysteine levels are elevated in patients who develop restenosis post PCI. <p>The study included fifty-one patients undergoing elective PCI who consented to participate in a protocol that was approved by the Ethics Committee of the University of Saskatchewan. Homocysteine and malondialdehyde were measured in the plasma and serum respectively. Blood samples were collected pre-procedural, 0 time, 8 hours, 24 hours, and 6 months post-procedure. Exercise tolerance tests were performed at two weeks, and six months post-procedure to determine if there was any evidence of restenosis. <p>The results of the study showed that pre-procedural values of plasma homocysteine in the restenosis and non-restenosis groups were 10.37 ± 0.46 and 10.73 ± 0.49 respectively. These values were not significantly different (p=0.60) between the groups. The pre-procedural levels of plasma homocysteine were not significantly different (p=0.08) from the post-PCI values of those patients who did not develop restenosis at the 6-month time interval. However, the pre-procedural levels of plasma homocysteine were significantly different from the post-PCI values of those patients in the restenosis group at the 24hr (p=0.04) and 6-month (p=0.002) time intervals. In the restenosis group there was a significant increase (24%) after six months in the values of homocysteine from the pre-procedural levels. Thus, this indicates that restenosis is associated with higher post-PCI levels of homocysteine. <p>The pre-procedural levels of serum MDA in the restenosis and non-restenosis groups were 0.124± 0.16 and 0.147± 0.02 respectively. There was no significant difference (p=0.60) between the two groups. There was also no significant difference (p=0.053) between the pre-procedural values and the 6-month post-PCI values in those patients who did not develop restenosis. However, there was a significant difference (p=0.001) between the pre-procedural values and the 6-month post-PCI values in those patients who developed restenosis. The levels of serum MDA in patients with restenosis at 6-months increased by 109% and were significantly different (p=0.001) in the restenosis group. <p>The results suggest that pre-procedural levels of plasma homocysteine and serum MDA were not predictors of restenosis following PCI. However, the post-PCI six-month levels of both homocysteine and MDA are predictors of restenosis. Moreover, the post-PCI levels of MDA were better predictors of restenosis than the post-PCI levels of homocysteine because the increase in MDA levels were greater at six months than the rise in homocysteine levels at the same time interval.

Flow mediated dilation (FMD) is a non-invasive test that assesses endothelial health and nitric oxide bioavailability; it is commonly used to examine changes in vascular health due to disease or de-conditioning. Currently, a wide variety of protocols are being used to assess upper and lower extremity conduit artery health. The current project was embarked upon to gain a better understanding of the FMD protocols currently being used to asses conduit artery FMD and how these results impact our understanding of a participant’s vascular health. More specifically occlusion duration, cuff placement and artery location were examined in three commonly examined conduit arteries. The FMD responses in the brachial artery (BA), superficial femoral artery (SFA), and popliteal artery (PA) of ten healthy men, mean age of 27, after five and/or two-minutes of distal occlusion were examined. When the two-minute protocol was performed on the SFA and PA, low-resistance static calf exercise was added to augment the shear stimulus. It was hypothesized that percent FMD and shear stress responses of the SFA and PA would not be significantly different after five-minutes of occlusion, thereby allowing leg conduit artery FMD to be performed on either artery. It was further hypothesized that there would be no significant differences between the shear stress and percent FMD responses of the leg conduit arteries after five or two-minutes of occlusion; inferring that shorter occlusion durations when combines with ischemic muscle contractions can be used to assess SFA or PA FMD. With regards to comparisons between arm and leg conduit arteries, it was hypothesized that there would be significant between limb differences in baseline diameter, FMD and shear stress post five-minutes of distal occlusion. These differences will be used to better understand the effects of artery location and size on conduit artery FMD IV responses. Limitations with the traditional edge-detection method of determining arterial diameter prompted the creation of a new method of measuring artery diameter, the center-based method. It was hypothesized that there would be no significant differences in the percent FMD and time to FMD after five-minutes of BA occlusion (n=7). The results of the current study demonstrated that five-minutes of calf occlusion elicited a significant PA FMD but not a significant SFA FMD. FMD post two-minutes of PA occlusion with exercise was not significantly different than that produced by five-minutes of occlusion. Conversely, two-minutes of calf occlusion with exercise was unable to elicit a SFA FMD response. Significant differences in shear stress and FMD were reported between arm and leg conduit arteries, demonstrating different responses to five-minutes of distal occlusion due to artery size and location. Finally, no significant differences were noted between FMD and time to FMD when the center-based or edge-detection method was used. This study has demonstrated that the calf occlusion protocol was unable to elicit a FMD response in the SFA FMD; this occlusion location is only able to elicit a PA FMD response. Furthermore, two-minutes of occlusion with one-minute of exercise can be used in place of the five-minute protocol to examine PA FMD but not SFA FMD. Differences between arm and leg conduit arteries are noted and it has been suggested that this is likely due to leg conduit artery adaptations to gravity. Lastly, preliminary data suggest that the center-based method is an appropriate method of measuring conduit artery diameter.

Restenosis is one of the major adverse outcomes of Percutaneous Coronary Intervention (PCI). Previous studies have shown conflicting reports for homocysteine as a predictor of restenosis following PCI. The conflicting reports may be due to oxidative factors (stimulation of polymorphonuclear leukocyte [PMNL]-induced reactive oxygen species generation, xanthine- xanthine oxidase, and arachidonic acid metabolism) other than homocysteine which could cause endothelial cell dysfunction leading to restenosis. Malondialdehyde (MDA), a lipid peroxidation product, is a marker for oxidative stress and is related to all oxidative factors. Therefore, it is possible that serum MDA may be a better predictor of restenosis than plasma homocysteine. The purpose of this study is to determine whether or not the pre-procedural serum MDA and plasma homocysteine levels are elevated in patients who develop restenosis post PCI. <p>The study included fifty-one patients undergoing elective PCI who consented to participate in a protocol that was approved by the Ethics Committee of the University of Saskatchewan. Homocysteine and malondialdehyde were measured in the plasma and serum respectively. Blood samples were collected pre-procedural, 0 time, 8 hours, 24 hours, and 6 months post-procedure. Exercise tolerance tests were performed at two weeks, and six months post-procedure to determine if there was any evidence of restenosis. <p>The results of the study showed that pre-procedural values of plasma homocysteine in the restenosis and non-restenosis groups were 10.37 ± 0.46 and 10.73 ± 0.49 respectively. These values were not significantly different (p=0.60) between the groups. The pre-procedural levels of plasma homocysteine were not significantly different (p=0.08) from the post-PCI values of those patients who did not develop restenosis at the 6-month time interval. However, the pre-procedural levels of plasma homocysteine were significantly different from the post-PCI values of those patients in the restenosis group at the 24hr (p=0.04) and 6-month (p=0.002) time intervals. In the restenosis group there was a significant increase (24%) after six months in the values of homocysteine from the pre-procedural levels. Thus, this indicates that restenosis is associated with higher post-PCI levels of homocysteine. <p>The pre-procedural levels of serum MDA in the restenosis and non-restenosis groups were 0.124± 0.16 and 0.147± 0.02 respectively. There was no significant difference (p=0.60) between the two groups. There was also no significant difference (p=0.053) between the pre-procedural values and the 6-month post-PCI values in those patients who did not develop restenosis. However, there was a significant difference (p=0.001) between the pre-procedural values and the 6-month post-PCI values in those patients who developed restenosis. The levels of serum MDA in patients with restenosis at 6-months increased by 109% and were significantly different (p=0.001) in the restenosis group. <p>The results suggest that pre-procedural levels of plasma homocysteine and serum MDA were not predictors of restenosis following PCI. However, the post-PCI six-month levels of both homocysteine and MDA are predictors of restenosis. Moreover, the post-PCI levels of MDA were better predictors of restenosis than the post-PCI levels of homocysteine because the increase in MDA levels were greater at six months than the rise in homocysteine levels at the same time interval.

The leading cause of death in patients who survive subarachnoid hemorrhage (SAH) is stroke as a result of cerebral arterial vasospasm1. Such vasospasms involve a vasoactive response, but they remain enigmatic and no clinical treatment has proven effective in prevention or reduction2. Arteries remodel in response to diverse mechanical loads and chemical factors. Following SAH, the surrounding vasculature is exposed to a radically altered chemo-mechanical environment. It is our hypothesis that chemical stimuli associated with the formation of an extravascular blood clot dominates the maladaptive growth and remodeling response early on, thus leading to important structural changes. However, it is not clear which of the many chemical factors are key players in the production of vasospasm. Before an accurate picture of the etiology of vasospasm can be produced, it is imperative to gain a better understanding of the non-pathogenic cerebral vasculature. In particular, the rabbit basilar artery is a well established model for vasospasm. However, surprisingly little is known about the mechanical properties of the rabbit basilar artery. Using an in vitro custom organ culture and mechanical testing device, acute and cultured basilar arteries from male White New Zealand specific pathogen free rabbits underwent cyclic pressurization tests at in vivo conditions and controlled levels of myogenic tone. Sections of basilar arteries were imaged for collagen fiber orientation at 0, 40 and 80 mmHg at in vivo stretch conditions using nonlinear optical microscopy. The nonlinear stress-strain curves provide baseline characteristics for acute and short-term culture basilar arteries. The active and passive testing creates a framework for interpreting the basal tone of arteries in our culture system. Nonlinear optical microscopy second harmonic generation provides unique microstructural information and allows imaging of live, intact arteries while maintaining in vivo geometries and conditions. Collagen fibers were found to be widely distributed about the axial direction in the adventitial layer and narrowly distributed about the circumferential direction in the adventitial layer. The quantified collagen fiber angles within the artery wall further support the development of accurate mathematical models.