Ischemic Spinal Cord Injury Research Articles

Acute Traumatic and Ischemic Spinal Cord Injuries Have a Comparable Course of Recovery

Background. The relative rarity of ischemic compared with traumatic spinal cord injury (SCI) has limited a comparison of the outcomes of these conditions. Objective. To investigate the neurological and functional recovery of ischemic compared with traumatic acute SCI. Methods. Data were derived from the European Multicenter Study Spinal Cord Injury database. Patients with ischemic (iSCI) or traumatic SCI (tSCI), aged 18 years or older were evaluated at different time points from incidence: at about 1 month, 3 months, and 6 months. The neurological status was assessed at each time point by the International Standards for Neurological Classification of Spinal Cord Injury and the functional status by the Spinal Cord Independence Measure. Walking ability was evaluated by Walking Index for Spinal Cord Injury, 10-Meter Walk Test, and 6-Minute Walk Test. Because of the imbalances of the 2 groups in respect to size and lesion severity, a matching procedure according to age, neurological level, and severity of injury was performed. Outcomes evaluation was performed by means of a 2-way repeated-measures ANOVA. Results. The matching procedure resulted in 191 pairs. Both groups significantly improved from about 15 days after the lesion to 6 months. No differences were found in the course of neurological and functional recovery of iSCI compared with tSCI. Conclusions. This analysis from a representative cohort of participants revealed that from 15 days following the cord damage onward, the outcomes after iSCI and tSCI are comparable. This finding supports the potential enrolment of patients with acute iSCI into clinical trials from that point in time after the event and an evaluation up to 6 months afterward.

Thoracic endovascular repair for retrograde acute type A aortic dissection as an alternative choice.

The purpose of this study was to determine the clinical outcomes of thoracic endovascular aortic repair in 8 patients with acute type A aortic dissection with an entry tear in the descending aorta. From January 2016 to December 2018, eight patients (mean age 76years; range 54-92years) were treated by thoracic endovascular aortic repair due to high operative risk for conventional open repair. All patients had significant comorbidities, and two had critical organ malperfusion due to aortic dissection. Surgical outcomes were retrospectively reviewed. All procedures were technically successful with complete coverage of the entry tear. The proximal landing zone was Zone 1 in 2, Zone 2 in 1, Zone 3 in 4, and Zone 4 in 1 patient. Patients requiring Zone 1 and 2 thoracic endovascular aortic repair underwent aortic arch bypass simultaneously. Mean operation time was 132min. There were no hospital deaths and no serious complications, including stroke and spinal cord ischemic injury. All patients had complete thrombosis and shrinkage of the false lumen in the ascending aorta before discharge. During up to 36-month follow-up (mean 20 ± 12months), there were no adverse aortic events except one who died due to ischemic colitis 4months after the procedure. Thoracic endovascular aortic repair could be a useful alternative surgical option for patients with retrograde acute type A aortic dissection with an entry in the descending aorta who are not suitable for conventional open surgery. Careful follow-up of such patients is mandatory.

Neurophysiological and paraspinal oximetry monitoring to detect spinal cord ischemia in patients during and after descending aortic repair: An international multicenter explorative study

BackgroundDuring descending aortic repair, critically decreased blood flow to the myelum can result in ischemic spinal cord injury and transient or permanent paraplegia. Assessment of motor evoked potentials (MEPs) has been shown to be a valuable tool which allows to detect spinal cord ischemia (SCI) intraoperatively within a therapeutic window suitable to prevent progression to paraparesis or paraplegia. MEP monitoring is not feasible during postoperative care in the awakening patient. Therefore, ancillary techniques to monitor integrity of spinal cord function are needed to detect delayed spinal cord ischemia. ObjectiveThe purpose of this study is to evaluate whether assessment of long loop reflexes (LLR; F-waves) and paraspinal muscle oximetry using Near-Infrared Spectroscopy (NIRS) are feasible and valid in detecting delayed SCI. MethodsWe aim to include patients from three tertiary referral centers undergoing aortic repair with MEP monitoring in this study.F-wave measurements and paraspinal NIRS oximetry will be operated intra- and postoperatively. Measurement characteristics and feasibility will be assessed in the first 25 patients. Subsequently, a second cohort of 75 patients will be investigated to determine the sensitivity and specificity of F-waves and NIRS in detecting perioperative SCI. In this context for the MEP group SCI is defined intraoperatively as significant MEP changes and postoperatively as newly developed paraplegia. ConclusionsA clinical study design and protocol is proposed to assess if F-waves and/or NIRS-based paraspinal oximetry are feasible and valid in detecting and monitoring for occurrences of delayed SCI.

Adeno-associated virus packaged TRPC5 gene therapy alleviated spinal cord ischemic reperfusion injury in rats.

Spinal cord injury (SCI) is a devastating disease with few effective treatments. This study mainly explored the mechanism of TRPC5 gene in the treatment of spinal cord ischemia reperfusion injury from the perspective of angiogenesis. Western blot, immunohistochemistry, hematoxylin and eosin, ELISA, and reverse transcription-PCR (RT-PCR) were used to detect the expression levels of related angiogenic proteins such as von Willebrend factor (vWF), vascular endothelial growth factor (VEGF), CD31, and HIF-1α. The results showed that compared with the IR group, the Basso, Beattie, and Bresnahan scores of IR + adeno-associated virus (AAV) + TRPC5 group were higher with significant difference. And compared with ischemia/reperfusion (I/R) group, RT-PCR and ELISA results showed that inflammatory factors such as IL-6, IL-1β, and TNF-α were significantly reduced in IR + AAV + TRPC5 group. In addition, the expression of vascular related proteins such as vWF, VEGF, and CD31 in spinal cord tissue were all increased. Taken together the results, we suggest that TRPC5 could significantly increase the expression of angiogenic protein and slow down the occurrence of inflammatory response to repair the SCI.

ISCHEMIC SPINAL CORD INJURY FOLLOWING AORTIC STENT GRAFT IMPLANTATION – CASE STUDY

Morbidity and mortality associated with aortic aneurysm remains high. Aneurysms involving the thoracic and lumbar part of the aorta (TAAA) are particularly burdened with mortality. They are also one of the biggest challenges that vascular surgeons can face. Despite several dozen years of progress in surgical techniques, as well as the constant development of accompanying methods of spinal protection, ischemic spinal cord injury with subsequent paresis or pareresis is still one of the most serious complications of both open and closed surgical treatment of aortic aneurysms. Ischemic complications of the spinal cord occur immediately after the procedure, when the patient wakes up with a neurological deficit (according to some authors within the first day after the procedure) or in a deferred manner. In the case of open surgery, immediate damage is more common, in the case of endovascular surgery - deferred. Factors such as low blood pressure, arrhythmias, cardiovascular failure, sepsis and anemia due to anemia contribute to an increased risk of deferred complications. The rehabilitation of a patient with limb paralysis as a consequence of vascular spinal injury is laborious and requires a comprehensive approach. Proper treatment and prompt intervention in the form of rehabilitation is a great therapeutic challenge. The aim of the paper was to present the importance of the ischemic injuries of spinal cord following aortic stent graft implantation through a case report.

Biodistribution of Site-Specific PEGylated Fibroblast Growth Factor-2.

Fibroblast growth factor 2 (FGF-2) is a small 18 kDa protein with clinical potential for ischemic heart disease, wound healing, and spinal cord injury. However, the therapeutic potential of systemic FGF-2 administration is challenged by its fast elimination. Therefore, we deployed genetic codon expansion to integrate an azide functionality to the FGF-2 N-terminus, which was site-directly decorated with poly(ethylene glycol) (PEG) through bioorthogonal strain-promoted azide-alkyne cycloaddition (SPAAC). PEGylated FGF-2 was as bioactive as wild-type FGF-2 as demonstrated by cell proliferation and Erk phosphorylation of fibroblasts. The PEGylated FGF-2 conjugate was radiolabeled with [111In] Indium cation ([111In]In3+) to study its biodistribution through noninvasive imaging by single-photon emission computed tomography (SPECT) and by quantitative activity analysis of the respective organs in healthy mice. This study details the biodistribution pattern of site-specific PEGylated FGF-2 in tissues after intravenous (iv) administration compared to the unconjugated protein. Low accumulation of the PEGylated FGF-2 variant in the kidney and the liver was demonstrated, whereas specific uptake of PEGylated FGF-2 into the retina was significantly diminished. In conclusion, site-specific PEGylation of FGF-2 by SPAAC resulted in a superior outcome for the synthesis yield and in conjugates with excellent biological performances with a gain of half-life but reduced tissue access in vivo.

Minimally Invasive Segmental Artery Occlusion Prior to Endovascular Repair of Thoraco-Abdominal Aortic Aneurysm to Reduce the Risk of Spinal Cord Injury

Introduction - Minimal invasive segmental artery occlusion (MISAO) has been clinically introduced as an entirely endovascular approach to stage the segmental artery (SA) sacrifice in several sessions prior to total endovascular repair (ER) of thoraco-abdominal aortic aneurysm (TAAA) and thereby reduce ischemic spinal cord injury (iSCI) (1,2). The aim of our study was to report on our initial clinical experience and the SCI rates after MISAO and endovascular repair of TAAA. Methods - A cohort of 39 patients (28 men, mean age 68.92±7.56 years) with extensive nonruptured TAAAs and no previous neurological deficit were treated by MISAO followed by fenestrated and multibranched endografting between October 2014 and March 2017. MISAO was performed in local anesthesia with clinical surveillance of the patients ‘neurological functions and hemodynamic stability for at least 48 hours. Final ER was performed after a minimum of one week after the last MISAO session. The main outcomes were the 30-day mortality and the onset of the SCI after ER. Results - The majority of patients (n=36) were treated for atherosclerotic aneurysm, whereas three patients were treated for post-dissection aneurysm. The TAAA distribution was as follow: type I, n= 5; type II, n=9; type III, n=20; type IV, n=5. The maximum aortic diameter was in average 62.74 ± 8.77mm. The mean number of patent SAs per patient was 11±4.5. A total of 245 SAs were occluded by MISAO with each patient having in median 6 coiled SAs (range: 1-19), occluding 75% of direct segmental arterial inflow (Range: 38.89% - 100%). MISAO preconditioning was completed in one (n=15), two (n=17), three (n=3), four (n=3) and five (n=1) sessions prior to TAAA-ER. The maximum number of coiled SAs per session was six and the maximum number of coiled SAs per patient was nineteen. In seventeen patients the inferior mesenteric artery was also coiled. The average interval time between sessions was 63.56 ± 70.69 days. No SCI and no other major complications developed. Minor complications were temporary back pain in eleven patients. After a mean of 77 ± 61.56 days thirty-eight of the patients received total ER of their TAAA. One patient died waiting for ER of TAAA. At 30 days postoperatively, thirty-seven patients were alive and none developed SCI. Conclusion - In our experience, minimal invasive segmental artery occlusion to precondition the paraspinous collateral network is clinically feasible and safe. MISAO followed by aneurysm exclusion may eliminate paraparesis and paraplegia after total endovascular repair of extensive TAAA.

Transapical aortic perfusion using a deep hypothermic procedure during descending thoracic or thoracoabdominal aortic surgery.

In descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) surgery, though proximal anastomosis using deep hypothermic circulatory arrest (DHCA) is often selected, there are issues surrounding brain and heart protection. In this study, the usefulness of concomitant upper body perfusion via transapical aortic cannulation during deep hypothermic surgery was examined. Between October 2014 and May 2019, 5 patients (Crawford extent II chronic dissection, N.=3; extent IV aneurysms, N.=1; DTAA, N.=1) underwent DTAA/TAAA repair under deep hypothermia using transapical aortic perfusion. A proximal anastomosis and artery of Adamkiewicz (AKA) reconstruction were performed under continuous perfusion of the upper and lower body at 20 °C. The time from aortic cross-clamping to proximal anastomosis was 69±33 minutes, and it took 86±47 minutes to AKA reperfusion. There was no spinal cord ischemic injury or brain or heart complications. One patient required tracheostomy, and the average postoperative intubation time for the other patients was 57±52 hours. All patients were discharged, and the average postoperative hospital stay was 25.6±8.1 days. Concomitant upper body perfusion by the transapical aortic approach contributes to avoidance of brain and heart complications and maintaining spinal cord circulation under deep hypothermic DTAA/TAAA surgery.

Cerebrospinal fluid drainage complications during first stage and completion fenestrated-branched endovascular aortic repair

ObjectiveTo determine the rates and risk factors of complications related to cerebrospinal fluid drainage (CSFD) during first stage and completion fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal and thoracoabdominal aortic aneurysms. MethodsWe reviewed the outcomes of 293 consecutive patients enrolled in a prospective, nonrandomized study to investigate outcomes of F-BEVAR between 2013 and 2018. Patients who received CSFD during first-stage thoracic endovascular aortic repair, index F-BEVAR, or completion of temporary aneurysm sac perfusion procedures were included in the analysis. CSFD complications were graded as severe or moderate if they were life threatening, escalated the level of care, or prolonged the hospital stay. Presence of substantial degenerative lumbar disease (DLD) was identified based on review of preoperative computed tomography. End points included technical difficulties during CSFD placement and CSFD-related complications. ResultsA total of 187 patients (mean age, 73 ± 8 years; 70% male) treated for 20 pararenal and 167 thoracoabdominal aortic aneurysms received CSFD in 240 procedures, including 51 first-stage thoracic endovascular aortic repairs, 184 index F-BEVARs, and 5 completion temporary aneurysm sac perfusion procedures. Nineteen patients (10%) had 22 CSFD-related complications after 21 aortic procedures (9%). Complications were graded as severe to moderate in 17 patients (9%). There were 12 patients (6%) with intracranial hypotension, including three (2%) who had intracranial hemorrhage and nine (5%) with post dural puncture headache requiring blood patches in six. Another six patients (3%) developed spinal hematomas resulting in paraplegia in two (1%) and transient paraparesis in two (1%). One patient had CSF leakage from the puncture site (no intervention required). Four patients had bleeding during attempted drain placement, which required postponement of F-BEVAR. Technical difficulties were experienced in 57 drain insertions (24%), more often in patients with DLD than in those without DLD (35/113 [31%] vs 22/121 [18%]; P = .03). Fluoroscopic guidance was used in 44 drain placements (18%) with a lower rate of technical difficulties compared with the blind approach (9% vs 28%; P = .01). There was a statistically nonsignificant trend toward more complications in patients with technical challenges (14% vs 7%; P = .10). Of 13 study patients who developed spinal cord injuries during aortic procedures, 4 (31%) were attributed to CSFD. ConclusionsAlthough CSFD is widely used to prevent ischemic spinal cord injury during complex aortic repair, the risk of major CSFD-related complications is not negligible and should be carefully weighed against its potential benefits. One-third of spinal cord injuries were caused by CSF drain placement. The use of fluoroscopic guidance may decrease the risk of CSFD-related complications.

Tissue bridges predict recovery after traumatic and ischemic thoracic spinal cord injury.

ObjectiveTo investigate the spatiotemporal evolution and predictive properties of intramedullary damage and midsagittal tissue bridges at the epicenter of a thoracic spinal cord injury (SCI) using MRI.MethodsWe retrospectively assessed midsagittal T2-weighted scans from 25 patients with thoracic SCI (14 traumatic, 11 ischemic) at 1 month post-SCI. In 12 patients with SCI, linear mixed-effects models on serial MRI explored temporal trajectories of quantifiable lesion markers (area, length, and width) and tissue bridges. Using partial correlation analysis, we assessed associations between structural lesion characteristics at 1 month post-SCI and recovery at 1 year postinjury, adjusting for baseline clinical status, age, and sex.ResultsLesion area decreased by 5.68 mm2 (p = 0.005), lesion length by 2.14 mm (p = 0.004), and lesion width by 0.13 mm (p = 0.004) per month. Width of tissue bridges increased by 0.06 mm (p = 0.019) per month, being similar in traumatic and ischemic SCI (p = 0.576). Smaller lesion area, length, width, and wider tissue bridges at 1 month post-SCI predicted better recovery at 1-year follow-up.ConclusionsOver time, the immediate area of cord damage shrunk while the cystic cavity became demarcated. Adjacent to the cyst, midsagittal tissue bridges became visible. The width of tissue bridges at 1 month post-SCI predicted recovery at 1 year follow-up. Measures of lesion area and tissue bridges early after traumatic and ischemic thoracic SCI therefore allow characterizing the evolution of focal cord damage and are predictive of recovery in thoracic SCI. Thus, lesion extent and tissue bridges hold potential to improve diagnosis and patient stratification in interventional trials.

The comparison of recovery patterns between ischemic spinal cord injury and traumatic spinal cord injury from acute to chronic phase

Objective: To investigate the neurological and functional recovery patterns of ischemic spinal cord injury (ISCI) compared with traumatic spinal cord injury (TSCI) in the acute to chronic phase. Design: Retrospective cohort study. Settings: Department of Neurology, Neurosurgery, Rehabilitation Medicine at a tertiary hospital. Participants: Fifty-four patients with ISCI and 86 patients with TSCI. Interventions: Not applicable. Outcome measures: MRI findings, American Spinal Injury Association Impairment Scale (AIS), modified Rankin Scale (mRS), Korean Spinal Cord Independence Measure (KSCIM), ambulatory status, and bladder status were reviewed. The functional outcomes were measured at admission, discharge, and >6 months after discharge. Results: AIS classification did not significantly change after 6 months in both ISCI and TSCI groups. Between admission and discharge, the proportion of patients needing a wheelchair or assistive device to ambulate decreased more in the ISCI group compared with the TSCI group [odds ratio (OR) 0.40, P = 0.04]. In addition, the proportion of catheterized voiding in the ISCI group was significantly higher than in the TSCI group at all time points (OR 5.12, P < 0.001). Lastly, both groups showed that functional improvement was the greatest between admission and discharge. In addition, the proportion of catheterized voiding decreased (Diff = −0.12, P = 0.019) and mRS score decreased (Diff=−0.48, P < 0.001) significantly in the ISCI group at >6 months post discharge. Conclusion: The ISCI group showed better recovery of mobility during inpatient rehabilitation period and worse recovery of bladder function as demonstrated by higher number of patients requiring bladder catheterization at all time points when compared with the TSCI group.

Silencing miR-21 induces polarization of astrocytes to the A2 phenotype and improves the formation of synapses by targeting glypican 6 via the signal transducer and activator of transcription-3 pathway after acute ischemic spinal cord injury.

Ischemic spinal cord injury (ISCI) results in the motor sensory dysfunction of the limbs below the injury site. In response to the injury, astrocytes develop into neuroprotective astrocytes [(neurotrophic reactive astrocytes (A2s)] to mitigate the damage. MicroRNA (miR)-21 can promote the development of neuroinflammation in previous studies. Our aim was to investigate the effect of miR-21 on its polarization. We used the abdominal aortic occlusion model in vivo. Immunohistochemistry was used to detect the distribution of A2s in the spinal cord. We used an oxygen glucose deprivation method to model astrocytes ischemia in vitro and tested proliferation, migration, and excitability of A2s using an 5-ethynyl -2'-deoxyuridine kit, wound scratch assay, and calcium-ion probe. After adjustment, we detected the model and target genes of A2s using PCR, Western blot, immunofluorescence, and chromatin immunoprecipitation. We demonstrated in vivo that naive astrocytes were transformed into A2s by ischemia. And in vitro miR-21, which can regulate the signal transducer and activator of transcription-3 pathway, can transform neurotoxic reactive astrocyte into A2. Moreover, we also verified the mechanism of A2s promoting synaptic formation and nerve growth. miR-21 is a switch to regulate the polarization of reactive astrocyte, and it promoted synapsis formation and nerites growth after acute ISCI.-Su, Y., Chen, Z., Du, H., Liu, R., Wang, W., Li, H., Ning, B. Silencing miR-21 induces polarization of astrocytes to the A2 phenotype and improves the formation of synapses by targeting glypican 6 via the signal transducer and activator of transcription-3 pathway after acute ischemic spinal cord injury.

SS08. Cerebrospinal Fluid Drainage Complications During First Stage and Completion Fenestrated-Branched Endovascular Aortic Repair

To determine the rates and risk factors of complications related to cerebrospinal fluid drainage (CSFD) during fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal and thoracoabdominal aortic aneurysms. We reviewed outcomes of 293 consecutive patients enrolled in a prospective, nonrandomized study to investigate outcomes of F-BEVAR between 2013 and 2018. Patients who received CSFD during first-stage thoracic endovascular aortic repair, index F-BEVAR or completion temporary aneurysm sac perfusion procedures were included in the analysis. CSFD complications were graded as severe or moderate if these were life threatening, escalated the level of care or prolonged hospital stay. Presence of degenerative lumbar disease (DLD) was identified based on review of computed tomography scans. End points included technical difficulties during CSFD placement and CSFD-related complications. A total of 187 patients (mean age, 73 ± 8 years; 70% male) treated for 20 pararenal and 167 thoracoabdominal aortic aneurysms received CSFD in 240 procedures, including 51 first-stage thoracic endovascular aortic repairs, 184 index F-BEVARs and 5 completion temporary aneurysm sac perfusion procedures. Nineteen patients (10%) had 22 severe to moderate CSFD-related complications after 21 aortic procedures (9%). There were 12 patients (6%) with intracranial hypotension, including 3 (2%) who had intracranial hemorrhage (Fig 1) and 9 (5%) with severe headache requiring blood patches in 6. Another six patients (3%) developed spinal hematomas (Fig 2) resulting in paraplegia in two (1%) or transient paraparesis in two (1%). Other complications were cerebrospinal fluid leakage in one patient (no intervention) and bleeding during attempted CSFD placement requiring postponement of index F-BEVAR in three. In addition, 20 patients (11%) had blood-tinged drainage or bleeding at the puncture site without any clinical sequela. Technical difficulties were experienced in 57 drain insertions (24%), more often in patients with DLD compared with those without DLD (35/113 [31%] vs 22/121 [18%]; P = .03). Fluoroscopic guidance was used in 44 CSFD placements (18%) with lower rate of technical difficulties compared with blind approach (9% vs 28%; P = .01). There was a statistically nonsignificant trend toward more complications in patients with technical challenges (14% vs 7%; P = .10). Of the 13 patients who developed spinal cord injuries during aortic procedures, 4 (31%) were attributed to CSFD placement. Although CSFD is widely used to prevent ischemic spinal cord injury during complex aortic repair, the risk of major CSFD-related complications is not negligible and should be carefully weighed against its potential benefits. Use of fluoroscopic guidance may reduce the risk of CSFD complications.Fig 2Spinal hematoma.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Two episodes of remote ischemia preconditioning improve motor and sensory function of hind limbs after spinal cord ischemic injury

Objectives: To investigate the effect of one and two remote ischemia preconditioning episodes (1-RIPC or 2-RIPC, respectively) on neuro-protection after spinal cord ischemic injury (SCI) in rats. Design: Experimental animal study. Setting: College of Medicine, King Khalid University, Abha, KSA. Interventions: Male rats (n = 10/group) were divided into control, sham, SCIRI, 1-RIPC + SCIRI, and 2-RIPC + SCIRI. SCI was induced by aortic ligation for 45 min and each RIPC episode was induced by 3 cycles of 10 min ischemia/10 min perfusion. The two preconditioning procedures were separated by 24 h. Outcome measures: after 48 h of RIPC procedure, Tarlov’s test, withdrawal from the painful stimulus and placing/stepping reflex (SPR) were used to evaluate the hind limbs neurological function. SC homogenates were used to measure various biochemical parameters. Results: Motor and sensory function of hind limbs were significantly improved and levels of MDA, AOPPs, PGE2, TNF-α, and IL-6, as well as the activity of SOD, was significantly decreased in SC tissue in either 1 or 2 episodes of RIPC intervention. Concomitantly, levels of total nitrate/nitrite and eNOS activity were significantly increased in both groups. Interestingly, except for activity of SOD, eNOS and levels of nitrate/nitrite, the improvements in all neurological biochemical endpoint were more profound in 2-RIPC + SCIRI compared with 1-RIPC + SCIRI. Conclusion: applying two preconditioning episodes of 3 cycles of 10 min ischemia/10 min perfusion, separated by 24 h, boost the neuro-protection effect of RIPC maneuver in rats after ischemic induced SCI in rats.

Comparison of early patency rate and long-term outcomes of various techniques for reconstruction of segmental arteries during thoracoabdominal aortic aneurysm repair.

This study aimed to analyse the early patency rate and long-term outcomes of reattached segmental intercostal arteries using graft interposition, single-cuff anastomosis or island reconstruction. We selected 172 consecutive patients who underwent open surgery for the thoracoabdominal aorta with reattachment of segmental arteries between October 1999 and March 2018. The early patency of segmental arteries was analysed using enhanced computed tomography. Segmental arteries were reconstructed using graft interposition (n = 111), single-cuff anastomosis (n = 38) or island reconstruction (n = 23). The hospital mortality was 6.4%. Twenty patients developed spinal cord ischaemic injury (permanent, n = 12 or transient, n = 8). Spinal cord injury was found in 16, 3 and 1 patients in the graft interposition, single-cuff anastomosis and island reconstruction groups, respectively. Overall, 475 segmental arteries were reattached (mean number per patient 2.8 ± 1.3). The overall early patency rate was 63.4%. The patency rates in island reconstruction (91.2%) and single-cuff anastomosis (77.1%) were significantly better than that in graft interposition (54.0%; P < 0.01). However, 6 patients with island reconstruction of segmental arteries had an aneurysm formation at the intercostal artery reconstruction site, of whom 4 patients underwent reoperation during follow-up. None of the patients with graft interposition or single-cuff reattachment had a patch aneurysm in segmental arteries. Island reconstruction and single-cuff anastomosis might offer better patency rates and prevent spinal cord ischaemic injury than graft interposition. Because some patients with island reconstruction required reoperation for patch aneurysms in segmental arteries, single-cuff anastomosis is preferable in terms of early- and long-term outcomes.

Optimal occlusion pattern for minimally invasive staged segmental artery coil embolization in a chronic porcine model.

Minimally invasive staged segmental artery coil- and plug embolization (MIS2ACE) has been introduced for spinal cord injury prevention prior to open or endovascular thoraco-abdominal aortic aneurysm repair. To date, no optimal pattern has been developed. The aim of this study was to identify the optimal MIS2ACE occlusion pattern. Twenty-five juvenile pigs were randomly assigned to 3 MIS2ACE occlusion patterns (2 stages) and a control group [single-stage segmental artery (SA) occlusion, N = 7]. The first pattern started with occlusion of all lumbar segmental arteries in the first stage and the remaining thoracic arteries in the second stage (regional pattern, N = 6). In group 2, an alternating approach with occlusion of every other SA in the first stage and the remainder in the second stage was used (alternating pattern, N = 6). The third pattern started with occluding the watershed area between thoracic level 12 and lumbar level 2 in the first stage and the remaining arteries in the second stage (watershed pattern, N = 6). Neurological assessment at 6-h intervals and spinal cord tissue perfusion measurements via microspheres at 6 time points were performed. At the end of the experiments, the spinal cord was histopathologically examined. An average of 6 ± 2 coils were used per SA. In the control group a total of 57% (N = 4) of animals experienced permanent paraplegia, 1 animal (16%) of the alternating and watershed intervention group suffered from permanent paraplegia. Animals from the staged regional pattern did not experience permanent paraplegia. Furthermore, no evidence of significant tissue damage was observed (P < 0.05 vs control). Tissue perfusion of the lumbar spinal cord in the regional pattern group recovered within 3 days after the second stage to 89.2 ± 47 percent-of-baseline (P = 0.393), whereas mean perfusion of the other 2 intervention groups and the control remained significantly lower compared to the baseline (35.7 ± 16%, 30.2 ± 11% and 63.2 ± 19, P < 0.05). This study provides evidence that MIS2ACE (minimally invasive staging) may result in less ischaemic spinal cord injury and favourable neurological outcomes compared to complete (1 stage) SA occlusion. A regional-based occlusion pattern (starting with the lumbar segmental arteries) seems to be the best 2-stage approach.

Anti-Inflammatory Effect of Lycopene on Experimental Spinal Cord Ischemia Injury via Cyclooxygenase-2 Suppression

Objective: Spinal cord ischemia/reperfusion injury (SCII) is a devastating complication following thoracoabdominal aortic surgeries, often leading to severe neurological deficits. We sought to examine the effects of lycopene, a naturally existing carotenoid with anti-inflammatory properties, in the treatment against SCII. Methods: Rats were assigned into four treatment groups: Sham (sham operation), SCII (SCII-induction), LY25, and LY50 (lycopene treatment at 25 or 50 mg/kg following SCII induction, respectively). Results: Lycopene treatment improved the recovery of neurological functions following SCII and suppressed the neuronal cell death and neuroinflammation at 14 days after SCII. Furthermore, Western blot assay revealed that lycopene treatment attenuated the SCII-induced increase in the protein levels of cyclooxygenase-2 (COX-2), nuclear factor-κB, and activate protein-1, as well as the reduction of heme oxygenase-1. Conclusion: Lycopene exerted neuroprotective functions in SCII and inhibited SCII-elicited neuroinflammation via COX-2 suppression.

Protective Effect of Contralateral, Ipsilateral, and Bilateral Remote Ischemic Preconditioning on Spinal Cord Ischemia Reperfusion Injury in Rats.

To evaluate the effect of different remote ischemic preconditioning (RIPC) methods in spinal cord ischemia-reperfusion (IR) injury. A total of 36 rats were distributed to the 6 groups: sham surgery, control (only spinal cord IR), unilateral (hind limb RIPC before spinal cord IR), bilateral (hind limbs RIPC before spinal cord IR), ipsilateral (hind and fore limbs RIPC to the right before spinal cord IR), contralateral (right hind limb and left fore limb as RIPC before spinal cord IR). Thirty minutes after RIPC, the spinal cord was subjected to ischemia for 60 minutes. Seventy two hours after IR, all rats were evaluated by neurological function, histological and biochemical examinations. The mean Motor Deficit Index (MDI) scores in the ipsilateral, contralateral, and bilateral groups were lower than that of the unilateral group (p < 0.05). The mean malondialdehyde (MDA) in ipsilateral group was lower than were control group (p < 0.05). The mean total antioxidant capacity (TAC) and the mean number of normal motor neurons in the experimental groups were significantly higher than increased control group (p < 0.05). The mean plasma levels of catalase in the contralateral, ipsilateral, and bilateral groups were significantly increased compared to control group (p < 0.05). The mean scores of white matter damage in contralateral, bilateral, and unilateral groups were lower than control group (p < 0.05). The results of this study show that contralateral, ipsilateral, and bilateral limb RIPC may reduce the complications of spinal cord ischemic injury.

METHODS OF PHYSIOTHERAPY FOR STUDY IN A SPINAL INSULT

Spinal stroke is a disease that is rare in neurological practice. Affects young people, mostly at the age of 30 years [2]. It may be ischemic or haemorrhagic. Etiological, ischemic spinal stroke is caused by atherosclerosis of the aorta and blood vessels of the spinal cord, muscle spasm, vasculitis, pregnancy, hemangioma or hernia [3, 4]. Hemorrhagic stroke is caused by dysplasia, tumors and blood diseases involving increased bleeding [1]. Spinal infarction most commonly develops in the basal spinal artery pool, which is responsible for the blood supply of the anterior 2/3 of the spinal cord tissue. Often, the disease starts with a sudden back pain with an enigmatic nature (in the area of the thoracic segment - Th 8), a gradually occurring weakness in the limbs and hypestesia, pelvic-tangle disorders [5]. The gait is very difficult to impossible.Purpose of the study: To test neurological tests in patients with spinal ischemic spinal cord injury. Assess their accessibility and reliability.

METHODS OF PHYSIOTHERAPY FOR STUDY IN A SPINAL INSULT

Spinal stroke is a disease that is rare in neurological practice. Affects young people, mostly at the age of 30 years [2]. It may be ischemic or haemorrhagic. Etiological, ischemic spinal stroke is caused by atherosclerosis of the aorta and blood vessels of the spinal cord, muscle spasm, vasculitis, pregnancy, hemangioma or hernia [3, 4]. Hemorrhagic stroke is caused by dysplasia, tumors and blood diseases involving increased bleeding [1]. Spinal infarction most commonly develops in the basal spinal artery pool, which is responsible for the blood supply of the anterior 2/3 of the spinal cord tissue. Often, the disease starts with a sudden back pain with an enigmatic nature (in the area of the thoracic segment - Th 8), a gradually occurring weakness in the limbs and hypestesia, pelvic-tangle disorders [5]. The gait is very difficult to impossible.Purpose of the study: To test neurological tests in patients with spinal ischemic spinal cord injury. Assess their accessibility and reliability.