1/5. Reversal of twice-delayed neurologic deficits with cerebrospinal fluid drainage after thoracoabdominal aneurysm repair: a case report and plea for a national database collection.Delayed neurologic deficits are an uncommon yet devastating complication of thoracoabdominal aortic aneurysm repair. The mechanisms involved in the development of delayed spinal cord ischemia remain ill defined. We report a case of complete reversal of delayed neurologic deficits with postoperative cerebrospinal fluid (CSF) drainage. After a thoracoabdominal aneurysm extent I repair, the patient experienced delayed paraplegia at 6 hours and again at 34 hours after the operation, with elevated CSF pressure (>10 mm Hg) on both occasions. Prompt CSF decompression completely reversed the neurologic deficits within hours after onset. The findings in this case further support the role of CSF drainage in spinal cord protection for patients who undergo thoracoabdominal aneurysm repair and make a plea for a national database collection.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
2/5. Delayed postoperative paraplegia complicating repair of type A dissection.We describe the very rare event of delayed transient paraplegia after repair of type A dissection of the aorta and discuss therapeutic options. We also suggest insertion of a spinal catheter as soon as there are signs or symptoms of spinal cord injury to drain spinal fluid and maximize the effect of elevated spinal cord perfusion pressure.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
3/5. Selective deep spinal hypothermia with vacuum-assisted cerebral spinal fluid drainage for thoracoabdominal aortic surgery.Recent experiences from several centers indicate that the overall risk of spinal cord ischemia during thoracoabdominal aortic aneurysm repair has decreased to 5-8%. The results from these centers are rather consistent, despite the use of a variety of spinal protection strategies. An alternative to the various distal aortic perfusion techniques is selective spinal cooling by cold saline lavage. The principle advantage of selective hypothermia is the avoidance systemic heparinization and extracorporeal by-passes, while affording comparable spinal protection. The primary method of spinal cooling was pioneered by Cambria et al. at massachusetts General Hospital. In their experience, paraplegia or paresis occurred in 6.9% of patients (5-year period, 170 cases). An alternative to the Cambria method utilizes readily available perfusion supplies and offers the potential advantages of lower cerebral spinal fluid-systemic blood pressure differences, more expedient cooling, and deeper spinal hypothermia. This report describes this method and the clinical course of a patient treated with it.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
4/5. Bilateral lower limb hypoesthesia after radical prostatectomy in the hyperlordotic position under general anesthesia.PURPOSE: To report a case of postoperative bilateral lower limb hypoesthesia occurring after surgery under general anesthesia in the hyperlordotic position for radical prostatectomy. The possible pathophysiologic mechanisms are discussed. Clinical features: This 52-yr-old patient was slightly overweight and was on fenofibrate for hypercholesterolemia. He had no history of cardiovascular disease. Arterial blood pressure was overall well maintained except for a very transient hypotension at surgical incision. Blood loss was moderate and did not require transfusion. Soon after recovery, the patient complained of paresthesia in both legs and neurological examination revealed bilateral lower limb hypoesthesia, compatible with an incomplete medullar syndrome at the level of T12-L1. On postoperative day one, a plain magnetic resonance imaging scan demonstrated a hyperintense signal in the spinal cord from T8 to T9 on T2-weighted images consistent with ischemia of the spinal cord whereas the heterogeneous aspect of the spinal cord was due to an unusually high fat content of the epidural space. Neurological signs improved progressively and one week later the patient had recovered normal sensory functions of both lower limbs. CONCLUSION: Although arterial ischemia is the most common cause of postoperative spinal cord injury, other mechanisms may be invoked. We raise the possibility that a combination of intraoperative risk factors (hypotension, excessive postural changes) with anatomic predispositions (increased epidural venous pressure or fat content, previous bone disease) can produce arterial and/or venous ischemia of the spinal cord.- - - - - - - - - - ranking = 2keywords = pressure (Clic here for more details about this article) |
5/5. spinal cord ischemia after elective stent-graft repair of the thoracic aorta.OBJECTIVES: Neurologic deficit after endovascular treatment of the thoracic aorta is a complication reported with variable frequency that may be associated with severe morbidity and mortality. The mechanism of spinal cord ischemia appears to be multifactorial and remains ill-defined. We reviewed our experience to investigate the determinants of paraplegia after stent-graft repair of the thoracic aorta, identify patients at risk, and assess the effectiveness of ancillary techniques. methods: Over a 5-year period (June 1999 to December 2004), 103 patients underwent elective endovascular repair of the thoracic aorta at a university referral center. Indications for treatment were atherosclerotic aneurysms in 88 patients, chronic type B dissection in 10 patients, and penetrating aortic ulcer in 5 patients. Four of the 103 patients affected with thoracoabdominal aortic aneurysms had hybrid procedures and were excluded from the cumulative analysis. Twelve patients with zone 0 and zone 1 aortic arch aneurysms were operated on with synchronous or staged surgical aortic debranching. Preoperative cerebrospinal fluid (CSF) drainage was instituted in seven selected patients. Neurologic deficits were assessed by an independent neurologist and classified as immediate or delayed. Patient demographics and perioperative factors related to the endovascular procedure were evaluated by using univariate statistical analyses. RESULTS: A primary technical success was achieved in 94 patients (94.9%). At a mean follow-up of 34 /- 14 months, a midterm clinical success was obtained in 90 patients (90.9%). Four patients (4.04%) had delayed neurologic deficit that completely resolved after the institution of CSF drainage, steroids administration, and arterial pressure pharmacologic adjustment. None of the four patients who underwent hybrid procedures for thoracoabdominal aortic aneurysms had paraplegia or paraparesis. Univariate analyses identified only a perioperative lowest mean arterial pressure (MAP) of <70 mm Hg as a significant risk factor (P < .0001). CONCLUSION: Perioperative hypotension (MAP <70 mm Hg) was found to be a significant predictor of spinal cord ischemia; hence, careful monitoring and prompt correction of arterial pressure may prevent the development of paraplegia. When the latter occurred, reduction of the CSF pressure by drainage was useful. patients with a previous or synchronous abdominal aortic repair may also benefit from CSF drainage as a perioperative adjunct.- - - - - - - - - - ranking = 4keywords = pressure (Clic here for more details about this article) |