SUMMARY
The results of stellate ganglion infiltration in 8 patients, suffering from psychosis with cerebral arteriosclerosis or senile psychosis, are discussed.
The rationale of this treatment is presented and a number of papers dealing with the effect of this method are briefly reviewed.
6 patients who were in an advanced state of organic mental deterioration showed only temporary or moderate improvement. Two patients in the early phase of senile organic psychosis showed marked improvement. One remains improved to date (1 year after completion of treatment), while the improvement of the other patient lasted for 3 months.
The tentative conclusions arrived at were that while stellate ganglion infiltration is not of great benefit to patients in the advanced stages of senile psychoses it seems to have good results in patients in the early phase of psychoses of late life. Although we had only 2 cases in this group, the results seem encouraging enough to explore the value of stellate ganglion infiltration in such patients.
The technique used is simple and complications did not occur.
INTRODUCTION
One of the important factors in the development of the organic psychoses of late life is the diminished blood supply of the brain. This has long been recognized in psychosis with cerebral arteriosclerosis. It seems that impaired cerebral blood flow also plays a role in the development of senile psychosis.
Freyhan and co-workers( 6) examined the cerebral blood flow of 10 patients by the nitrous oxide method; 6 of those patients suffered from psychosis with cerebral arteriosclerosis, the other 4 from senile psychosis. There was a significant decrease blood flow in all 10 patients.
Both conditions exist simultaneously and it seems reasonable to assume that such patients would benefit from improved cerebral blood circulation.
It has been suggested by various authorities that stellate ganglion block (SGB) increases the cerebral blood circulation. In this paper, case histories of 8 patients who were treated by this method are presented. All of these patients suffered from organic psychoses of late life.
SGB by procaine was first introduced by Mandl in 1925 (9) for the treatment of angina pectoris. Later on, it was given to patients suffering from various neurological conditions (7, 8, 10, 11) on the assumption that the SGB would dilate cerebral blood vessels. Mandl applied stellate ganglion infiltration by the posterior approach. Subsequently, the anterior, anterolateral, and external approach as well as various modifications were introduced (12).
Risteen and Volpitto (11) reported on the result of stellate ganglion block in a group of 275 patients, all of whom had been suffering from neurological illnesses caused by various disorders of the brain. An important finding was hemiplegic patients showed improvement in motor function as the result of relaxation of muscle tone.
Karnosh and Gardner (8) reported on 500 patients who either had procaine block of both stellate ganglia or were subjected to reresection of the cervical ganglia. Persons affected with almost every type of organic brain disease as well as patients suffering from melancholia were included in this group. The authors were impressed by the fact that 6o% of the patients showed improvement in mood. A number of patients recovered from severe headaches, became less irritable, showed loss of anxiety, and slept better. The authors suggested that the effect of SGB might be caused by improved blood supply of the thalamus.
Gilbert and Takats (7) performed stellate ganglion block on 25 patients with cerebral embolus and thrombosis and obtained good results in 19 patients. Naffziger and Adams (10) performed SGB on 155 patients with cerebral thrombosis, embolus, or vaso-spasm and claimed neurological improvement in a number of patients within 5 to 10 minutes after infiltration. Aymes and Perry (1) reported on 44 cases and stated that stellate block is so far the most effective treatment of acute cerebral embolism and thrombosis.
The patients discussed in this paper received between 6 and i6 bilateral SGB during a period of several weeks; these blocks were given 3 to 4 times weekly. The anterior approach was used and about 12 c.c. of 1% procaine were injected in each ganglion; every infiltration was followed by Homer’s syndrome, i.e., constriction of pupils and narrowing of palpebral fissures. The syndrome disappeared within a few hours. No untoward complications were noted except that some patients complained of dizziness which was of short duration.
All patients were observed for a number of weeks after completion of their treatment. All were between 48 and 76 years of age, and most of them had been suffering from advanced stages of psychosis with cerebral arteriosclerosis or senile psychosis.
COMMENT
We present case reports of 8 patients who received SGB. This treatment was administrated with the intention of dilating cerebral blood vessels and improving oxygen supply to the brain of patients suffering from organic psychoses of old age.
It is known that sympathetic and parasympathetic fibers supply the muscles of blood vessels of the brain (2, 4, 5). Forbes and Wolf (3) observed that stimulation of sympathetic nerves in cats caused a constriction of about 10% of the diameter of cerebral blood vessels. Risteen and Volpitto (11) noticed by direct observation through burr openings, an immediate increase in the size of vessels of the brain, following ganglion block. Naffziger and Adams (10) noticed a consistent rise in cerebrospinal fluid pressure for a period of 20 to 40 seconds following SGB, suggesting a transient increase in the amount of blood entering the cranial cavity.
A number of authors have expressed doubt that the comparatively weak sympathetic control over cerebral blood vessels could have any significant effect on cerebral blood flow. However, the clinical picture of neurological phenomena such as fleeting paresis, aphasia, etc., as well as reports of clinical improvement of patients with cerebral embolism and thrombosis as a result os SBG ( (Risteen and Volpitto, Karnosh and Gardner, Gilbert and Takats, Naffziger and Adams, Aymes and Perry), would support the assumption that sympathetic vasoconstriction of cerebral blood vessels may play an important role in certain organic conditions.
Only one of our patients has maintained his improvement up to date (1 year after completion of treatment). The other patients showed only temporary or moderate improvement. Psychological tests were repeated after treatment for 5 patients and some improvement was shown in 3 oh them.
Although it had been planned to administer this treatment only to patients in the early phase of organic psychosis of senility the material available advanced stages.
Our group was far too small to allow a just evaluation of this method; furthermore these patients were kept longer in the hospital and received more attention than patients with similar conditions but not being treated with SGB. Our patients were hold that they were given treatment for the purpose of helping them; however, most of them had little insight and did not want to be treated; some were afraid of the infiltration.
It was not possible to evaluate these psychological factors, as practical considerations did not allow us to keep a control group of patients without giving them procaine infiltrations. At no time was any form of psychotherapy applied.
We believe that certain tentative conclusions can be drawn from our study. For this purpose we will divide our patients into 2 groups, one consisting of 6 patients who showed signs of advanced organic psychosis and the other of 2 patients who showed signs of the early phases.
The results in the first group were as follows: One was transferred to a state hospital after completion of treatment; 3 were discharged to their families but they were returned to hospital after 5 to 18 days and had to be transferred to a state hospital; one remained home but his conviction on discharge was considered only moderately improved; although he did not express delusional ideas, he did not gain insight and remained preoccupied and moderately depressed; one patient was discharged to a home for aged but was returned to hospital after 6 weeks with a statement by his doctor that his improvement had lasted for only 3 weeks.
Our second group consisted of only 2 patients. One recovered from his psychotic episode and 1 year after discharge has maintained his improvement. The other showed a dramatic improvement after 2 infiltrations; This marked improvement lasted for about 3 months. This patient had been severely depressed and had made a suicidal attempt. It will be remembered that Karnosh and Gardner (8) were impressed by the improvement in mood of 60% of their patients after stellate ganglion infiltration.
Those results lead us to believe that stellate ganglion infiltration is not of great value in patients who are in an advanced stage of a senile organic psychosis. It appears that these patients have such severe brain pathology that brief improvement of the circulation of the brain results only in temporary or moderate clinical improvement.
On the other hand, the patients in our second group showed a much better response to stellate ganglion infiltration. We assume that patients in the early phase of senile organic psychosis can be helped ti integrate on a more realistic level of adjustment by temporary and repeated improvement of brain circulation. Furthermore, a period os several months of improvement will make ir possible to give such patients psychotherapy in an attempt to maintain their improvement.
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