Regulation of the cerebral circulation by arterial carbon dioxide

Intact, coordinated, and precisely regulated cerebrovascular responses are required for the maintenance of cerebral metabolic homeostasis, adequate perfusion, oxygen delivery, and acid-base balance during deviations from homeostasis. Increases and decreases in the partial pressure of arterial carbon dioxide (PaCO₂) lead to robust and rapid increases and decreases in cerebral blood flow (CBF). In awake and healthy humans, PaCO₂ is the most potent regulator of CBF, and even small fluctuations can result in large changes in CBF. Alterations in the responsiveness of the cerebral vasculature can be detected with carefully controlled stimulus-response paradigms and hold relevance for cerebrovascular risk in steno-occlusive disease. As changes in PaCO₂ do not typically occur in isolation, the integrative influence of physiological factors such as intracranial pressure, arterial oxygen content, cerebral perfusion pressure, and sympathetic nervous activity must be considered. Further, age and sex, as well as vascular pathologies are also important to consider. Following a brief summary of key historical events in the development of our understanding of cerebrovascular physiology and an overview of the measurement techniques to index CBF this review provides an in-depth description of CBF regulation in response to alterations in PaCO₂. Cerebrovascular reactivity and regional flow distribution are described, with further consideration of how differences in reactivity of parallel networks can lead to the “steal” phenomenon. Factors that influence cerebrovascular reactivity are discussed and the mechanisms and regulatory pathways mediating the exquisite sensitivity of the cerebral vasculature to changes in PaCO₂ are outlined. Finally, topical avenues for future research are proposed.