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1/22. Acute bilateral arm paresis.

    OBJECTIVE: To study pure motor bilateral arm paresis of acute onset. This syndrome is as yet a barely described clinical feature attributed to ischemia in the territory of the anterior spinal artery (ASA). CASES: We present 2 patients with acute onset of pure motor deficit in both upper extremities. RESULTS: magnetic resonance imaging of the cervical spinal cord revealed infarcts in the territory of the ASA. In 1 case, electrophysiology further suggested discrete gray matter involvement. CONCLUSION: In patients with acute weakness of both arms without further neurological deficits, an incomplete ASA syndrome should be considered with the anterior horns predominantly being affected. magnetic resonance imaging and electrophysiology are valuable tools to further confirm both location and extension of the spinal lesion. ( info)

2/22. anterior spinal artery syndrome following total hip arthroplasty under epidural anaesthesia.

    We present a case of anterior spinal artery syndrome in a 57-year-old man having a total hip arthroplasty under epidural anaesthesia. Epidural insertion and surgery were uneventful. Postoperatively bilateral lower limb motor weakness was attributed to the initial dose of local anaesthetic. There was no change in neurological status 24 hours later. magnetic resonance imaging demonstrated spinal cord infarction. The diagnosis of anterior spinal artery syndrome was made based on the patient's neurological condition and MRI findings. ( info)

3/22. Ischemic spinal cord syndrome after transthoracic esophagectomy: two cases of a rare neurologic complication.

    anterior spinal artery syndrome (ASAS) is a rare complication after surgery of the thoracic or abdominal aorta. The sulco commissuralis syndrome represents a partial or incomplete ASAS. We report two cases of ischemic spinal cord syndromes after transthoracic esophagectomy. This represents a prevalence of this syndrome of 0.2% in more than 1000 consecutive esophagectomies performed at our institution. Patient 1 developed an ASAS on the first day after esophagectomy. Patient 2 showed the pathognomonic clinical signs associated with sulco commissuralis syndrome after an asymptomatic window. In both patients, the extent of the neurologic symptoms initially improved but then remained unchanged for the rest of the follow-up of 9 and 12 months. Although the prognosis of neurologic syndromes resulting from spinal cord infarction is poor, preoperative tests to identify patients at risk appear not to be justified because of the very low incidence of these syndromes after esophagectomy and the poor sensitivity and specificity of currently available diagnostic modalities. However, the possibility of ischemic spinal cord syndrome should be kept in mind when patients present with neurologic symptoms after esophagectomy. ( info)

4/22. anterior spinal artery syndrome in an adolescent with protein s deficiency.

    The diagnosis of anterior spinal artery syndrome can be made with high accuracy by thorough clinical examination in combination with typical magnetic resonance imaging findings. Sudden onset of tetra- or paraparesis and dissociated sensory loss with bladder dysfunction are the leading clinical signs. We discuss clinical and radiologic findings in an adolescent presenting with anterior spinal artery syndrome. The laboratory results showed a hereditary protein s deficiency. ( info)

5/22. Postoperative epidural analgesia and possible transient anterior spinal artery syndrome.

    BACKGROUND AND OBJECTIVE: We present an unusual complication of epidural analgesia used to facilitate postoperative pain relief while allowing mobilization of the patient. CASE REPORT: A 65-year-old woman with a history of chronic obstructive pulmonary disease, atherosclerotic cardiovascular disease, chronic renal failure, and degenerative vertebral anatomy underwent resection of the left ureter due to obstructing tumor. The day following surgery, mobilization to an armchair was started, followed by a decrease in blood pressure. Soon after, flaccid paralysis with sparing of sensory functions, consistent with anterior spinal artery syndrome (ASAS), was diagnosed. CONCLUSIONS: This complication should be taken into account, especially in patients at risk, when considering epidural analgesia techniques in the postoperative period. Reg Anesth pain Med 2001;26:274-277. ( info)

6/22. anterior spinal artery syndrome after aortic surgery in a child.

    anterior spinal artery syndrome is rare in children. In adults, where it is observed most frequently after resection of thoracoabdominal aortic aneurysms, spinal magnetic resonance imaging is considered the first-line investigation to confirm the clinical diagnosis. A 3-year-old male who presented with this syndrome after palliative cardiac surgery for a complex cardiac malformation associated with aortic coarctation is presented. Clinical diagnosis of anterior horn cell impairment below the L2 level was confirmed by electromyography and F-wave studies. Sparing of dorsal sensory tracts was documented by normal somatosensory-evoked potentials, which confirmed the anterior localization of the lesion. Spinal magnetic resonance imaging performed on day 15 and day 105 after surgery was normal. Neurologic deficits, including flaccid paraplegia, remained stable except for the reappearance of patellar reflexes on day 83. Neurophysiologic conduction studies were consistent with lower motoneuron loss. In this patient, magnetic resonance imaging was less sensitive in demonstrating spinal cord lesion than clinical neurophysiology. Somatosensory-evoked potentials failed to detect the insult. Prevention may therefore require other neurophysiologic monitoring techniques. ( info)

7/22. Cruciate paralysis or man-in-the-barrel syndrome? Report of a case of brachial diplegia.

    A patient who developed isolated brachial diplegia following cardiac surgery is described. The underlying cerebral lesion could not be localized using magnetic resonance imaging (MRI). evoked potentials disclosed normal findings, while pathological latencies were seen on cortical magnetic stimulation. Their marked improvement over the following year was accompanied by almost complete clinical recovery. The preserved arm reflexes, together with the observed slow firing motor units in electromyography argued against bilateral lesions of the brachial plexus. We attribute the observed diplegia to a medullary lesion at the level of the pyramidal decussation, presumably caused by an intraoperative embolic occlusion of the anterior spinal artery. Cruciate paralysis and man-in-barrel-syndrome (MIBS) both are terms used to describe brachial diplegia; cruciate paralysis when caused by medullary lesions, MIBS when caused either by supratentorial or by medullary lesions. Exclusive use of the term MIBS for bilateral frontal lobe lesions, as in the original description, would provide more clarity in terminology. ( info)

8/22. anterior spinal artery syndrome after elective coronary artery bypass grafting.

    A 65-year-old patient with ischemic heart disease and hypertensive nephropathy had paraplegia develop after elective coronary artery revascularization caused by anterior spinal infarction. Spinal complications are rare after coronary artery bypass grafting. The possible mechanisms of spinal cord injury are discussed, and the relevant literature is reviewed. ( info)

9/22. Bilateral vocal fold paralysis and adhesion in anterior spinal artery syndrome.

    The purpose of this report is to present a rare case of anterior spinal artery syndrome (ASAS) in which there proved to be a combined lesion of paralysis and adhesion. A 26-year-old woman with a history of ASAS complained of difficulty of tracheal decannulation. In 1988, she was intubated and underwent tracheotomy because of respiratory muscle weakness, and she was decannulated in 1990. In 1998, she had cesarean delivery under general anesthesia, and postdelivery dyspnea necessitated tracheotomy again. On her first visit to us, endoscopic examination revealed bilateral vocal fold immobility at the midline without an apparent web. Direct laryngoscopy under general anesthesia revealed a posterior glottic adhesion and scarring, which were treated by excision of the scar and local steroid injection. The left vocal fold gradually regained mobility, permitting decannulation 3 months after treatment. This complicated vocal fold immobility was found to be due to adhesion and partial paralysis combined. ( info)

10/22. Combination of infarctions in the posterior inferior cerebellar artery and anterior spinal artery territories.

    After an episode of vasodilator-induced systemic hypotension, a 75-year-old man developed ocular lateropulsion to the right, left-side-dominant quadriparesis, loss of superficial sensation below C4 dermatome level, and anuresis. magnetic resonance imaging (MRI) showed infarcts in the right cerebellar hemisphere (posterior inferior cerebellar artery territory) and the upper cervical cord (anterior spinal artery territory); the combination of posterior inferior cerebellar artery (pica) and anterior spinal artery (ASA) infarcts has not been reported previously. angiography revealed severe stenosis in the bilateral vertebral arteries. Hemodynamic hypoperfusion of the stenotic vertebral arteries may cause this unusual combination. ( info)
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