Spinal Cord Perfusion Research Articles

Non-linear Dynamical Analysis of Intraspinal Pressure Signal Predicts Outcome After Spinal Cord Injury.

The injured spinal cord is a complex system influenced by many local and systemic factors that interact over many timescales. To help guide clinical management, we developed a technique that monitors intraspinal pressure from the injury site in patients with acute, severe traumatic spinal cord injuries. Here, we hypothesize that spinal cord injury alters the complex dynamics of the intraspinal pressure signal quantified by computing hourly the detrended fluctuation exponent alpha, multiscale entropy, and maximal Lyapunov exponent lambda. 49 patients with severe traumatic spinal cord injuries were monitored within 72 h of injury for 5 days on average to produce 5,941 h of intraspinal pressure data. We computed the spinal cord perfusion pressure as mean arterial pressure minus intraspinal pressure and the vascular pressure reactivity index as the running correlation coefficient between intraspinal pressure and arterial blood pressure. Mean patient follow-up was 17 months. We show that alpha values are greater than 0.5, which indicates that the intraspinal pressure signal is fractal. As alpha increases, intraspinal pressure decreases and spinal cord perfusion pressure increases with negative correlation between the vascular pressure reactivity index vs. alpha. Thus, secondary insults to the injured cord disrupt intraspinal pressure fractality. Our analysis shows that high intraspinal pressure, low spinal cord perfusion pressure, and impaired pressure reactivity strongly correlate with reduced multi-scale entropy, supporting the notion that secondary insults to the injured cord cause de-complexification of the intraspinal pressure signal, which may render the cord less adaptable to external changes. Healthy physiological systems are characterized by edge of chaos dynamics. We found negative correlations between the percentage of hours with edge of chaos dynamics (−0.01 ≤ lambda ≤ 0.01) vs. high intraspinal pressure and vs. low spinal cord perfusion pressure; these findings suggest that secondary insults render the intraspinal pressure more regular or chaotic. In a multivariate logistic regression model, better neurological status on admission, higher intraspinal pressure multi-scale entropy and more frequent edge of chaos intraspinal pressure dynamics predict long-term functional improvement. We conclude that spinal cord injury is associated with marked changes in non-linear intraspinal pressure metrics that carry prognostic information.

Using Laser Doppler Imaging and Monitoring to Analyze Spinal Cord Microcirculation in Rat.

Laser Doppler flowmetry (LDF) is a noninvasive method for blood flow (BF) measurement, which makes it preferable for measuring microcirculatory alterations of the spinal cord. In this article, our goal was to use both Laser Doppler imaging and monitoring to analyze the change of BF after spinal cord injury. Both the laser Doppler image scanner and the probe/monitor were being employed to obtain each readout. The data of LDPI provided a local distribution of BF, which gave an overview of perfusion around the injury site and made it accessible for comparative analysis of BF among different locations. By intensely measuring the probing area over a period of time, a combined probe was used to simultaneously measure the BF and oxygen saturation of the spinal cord, showing overall spinal cord perfusion and oxygen supply. LDF itself has a few limitations, such as relative flux, sensitivity to movement, and biological zero signal. However, the technology has been applied in clinical and experimental study due to its simple setup and rapid measurement of BF.

Reader response: Spinal cord perfusion pressure predicts neurologic recovery in acute spinal cord injury.

Squair et al.1 proposed that maintaining spinal cord perfusion pressure (SCPP) above 50 mm Hg and monitoring intrathecal pressure led to improved outcome but did not correlate with mean arterial pressure (MAP) or intraspinal CSF pressure. The 2013 update of guidelines for acute cervical spine and spinal cord injuries management advocated maintaining MAP about 85–90 mm Hg using even double inotrope support.2 SCPP is a dynamic process and may be higher for hypertensive patients and widespread microvascular disease; remains changing in the same traumatic spinal cord injury case; and intraspinal pressure value may be variable across the injury segment because cord edema, hematoma, and vertebral body fracture segments may impede free circulation of CSF.

Editors' note: Spinal cord perfusion pressure predicts neurologic recovery in acute spinal cord injury

Squair et al. studied whether spinal cord perfusion pressure (SCPP) as measured with a lumbar intrathecal catheter was a more predictive measure of neurologic outcome than the conventionally measured mean arterial pressure (MAP). They found that maintaining SCPP above 50 mm Hg was a strong predictor of improved neurologic recovery following spinal cord injury and suggested that SCPP could provide useful information to guide the hemodynamic management of patients with acute spinal cord injury. Dr. Satyarthee critiques the article, stating that SCPP is a dynamic process and that the study had limitations such as the small sample size, short observation period, and arbitrary 50 mm Hg SCPP critical point labeling. Squair et al. concur that further work is needed to define the role of SCPP monitoring in acute spinal cord injury. However, they explain that the 50 mm Hg SCPP point was not chosen arbitrarily; rather it was determined by statistically examining all possible cutoffs associated with poor neurologic outcome. They also add that the MAP goal of 85–90 mm Hg recommended in the 2013 guidelines cited by Dr. Satyarthee were based upon 2 studies with cohorts considerably smaller than the current study. Squair et al. studied whether spinal cord perfusion pressure (SCPP) as measured with a lumbar intrathecal catheter was a more predictive measure of neurologic outcome than the conventionally measured mean arterial pressure (MAP). They found that maintaining SCPP above 50 mm Hg was a strong predictor of improved neurologic recovery following spinal cord injury and suggested that SCPP could provide useful information to guide the hemodynamic management of patients with acute spinal cord injury. Dr. Satyarthee critiques the article, stating that SCPP is a dynamic process and that the study had limitations such as the small sample size, short observation period, and arbitrary 50 mm Hg SCPP critical point labeling. Squair et al. concur that further work is needed to define the role of SCPP monitoring in acute spinal cord injury. However, they explain that the 50 mm Hg SCPP point was not chosen arbitrarily; rather it was determined by statistically examining all possible cutoffs associated with poor neurologic outcome. They also add that the MAP goal of 85–90 mm Hg recommended in the 2013 guidelines cited by Dr. Satyarthee were based upon 2 studies with cohorts considerably smaller than the current study.

Author response: Spinal cord perfusion pressure predicts neurologic recovery in acute spinal cord injury.

We thank Dr. Satyarthee for the comments about our article.1 It is correct that we did not correlate the spinal cord perfusion pressure (SCPP) with mean arterial pressure (MAP); however, because SCPP is mathematically calculated from MAP, there is a relationship between the two by default. The important finding is that they are not equivalent with regards to predicting subsequent neurologic recovery. We recognize that SCPP is dynamic and that the optimal SCPP remains unknown (and probably differs from patient to patient). By statistically iterating through all possible cutoffs, we identified 50 mm Hg of SCPP as the point below which an increased risk for poor neurologic improvement starts to appear (figure 2).1 This 50 mm Hg threshold was not chosen arbitrarily, as Dr. Satyarthee suggests. As for the small sample size, we accept this limitation; the MAP goal of 85–90 mm Hg recommended in the 2013 guidelines that Dr. Satyarthee cites is largely based upon 2 studies with cohorts considerably smaller than ours.2,3 Nonetheless, we concur that further work is needed to define the role of SCPP monitoring in acute spinal cord injury.

Current strategies of spinal cord protection during thoracoabdominal aortic surgery.

Despite improved survival rates after thoracoabdominal aortic aneurysm repairs, paraplegia remains a devastating complication with high incidence, ranging from 3 to 10%. Ischemic insults to the spinal cord are unavoidable during thoracoabdominal aortic aneurysm repairs. There is no single measure that can prevent paraplegia alone. A multimodality approach is required to minimize the ischemic insults during thoracoabdominal aortic aneurysm repairs and postoperative second hit to the spinal cord. Distal aortic perfusion is important to maintain the collateral network perfusion pressure, while cerebrospinal drainage allows to directly maintain the spinal cord perfusion. Reattachment of segmental arteries T8-T12 is encouraged to lower the incidence of both immediate and delayed paraplegia. Systemic arterial pressure should be maintained above 130mmHg and cerebrospinal drainage should be continued until the second postoperative day, despite intact neurological status. In this article, we describe our current operative techniques and perioperative management in patients undergoing repairs of thoracoabdominal aortic aneurysm. A review of recent updates on spinal protection strategies is also reported.

New insights into spinal cord ischaemia after thoracic aortic procedures: the importance of the number of anterior radiculomedullary arteries for surgical outcome.

Anterior radiculomedullary arteries (ARMAs) link dorsal segmental arteries and the intraspinal compartment of the spinal collateral network. The number of thoracic ARMA is highly variable from one person to another. The impact of the number of ARMAs on spinal cord perfusion during thoracic aortic procedures is unknown. We investigated the influence of the number of thoracic ARMAs on spinal cord perfusion in an aortic surgical large animal model. Twenty-six pigs were included (20 treatment animals, 6 sham animals, weight 34 ± 3 kg). The animals underwent ligation of the left subclavian artery and the thoracic segmental arteries via a left lateral thoracotomy with normothermia. After sacrifice, complete body perfusion with coloured cast resin was performed and the number of thoracic ARMAs was documented at autopsy. End points were spinal cord perfusion pressure, cerebrospinal fluid pressure, spinal cord blood flow (microspheres) and neurological outcome. Observation time was 3 h post-ligation. The numbers of thoracic ARMAs ranged between 3 (n = 1) and 13 (n = 1). The mean number was 8. Animals were grouped according to number of thoracic ARMA: 6-7 (5 animals), 8-10 (8 animals) and 11-13 (5 animals). A large number of thoracic ARMAs was linked to (i) a lower drop in spinal cord blood flow from baseline to post-clamp, (ii) the presence and increased magnitude of hyperaemia evident 3 h post-clamp (P < 0.001) and (iii) the presence of early hyperaemia starting immediately post-clamp in animals with 11 or more ARMA (P < 0.001). We showed that a large number of thoracic ARMA protects against spinal cord injury during descending aortic surgical procedures.1.

Risk factors for spinal cord ischaemia after thoracic endovascular aortic repair.

Spinal cord ischaemia (SCI) is a serious complication of thoracic endovascular aortic repair (TEVAR). The purpose of this study was to assess the incidence, risk factors, clinical manifestations of SCI after TEVAR and which type of patients could benefit from cerebrospinal fluid drainage. A retrospective review was conducted for 175 patients who underwent TEVAR from January 2008 to July 2014. All patients were divided into groups with and without SCI, and they were compared to identify significant risk factors for SCI. The incidence of SCI after TEVAR including paraplegia and paraparesis was 6.9%. SCI usually occurred within 24 h, but delayed SCI was observed after 5 days in 1 patient. In all patients with SCI, we tried to increase the blood pressure to improve spinal perfusion. Three patients recovered completely, and the 6 patients with some remaining neurological deficit included 3 with motion against gravity and bladder dysfunction and the 3 remaining patients with only bladder dysfunction. Three patients did not recover. In our study, significant risk factors for SCI were as follows: rupture, shaggy aorta, chronic obstructive pulmonary disease, 1-stage procedure, the coverage of more than 9 segments, the coverage from Th8 to Th12, minimum of postoperative haemoglobin and the number of postoperative patent segmental arteries. Sufficient perioperative care should be given to high-risk patients who have endografts that cover more than 9 segments and endografts that cover segments from Th8 to Th12. Adequate haemoglobin levels and mean arterial pressure are needed to provide sufficient spinal cord perfusion.

Spinal cord injury in endovascular thoracoabdominal aortic aneurysm repair: prevalence, risk factors and preventive strategies.

Thoracoabdominal aortic aneurysms are among the most challenging pathologic conditions vascular surgeons have to face. Endovascular treatment brought the prospect of being able to treat these complex aneurysms with less invasiveness and recent outcomes already challenge those of open repair. Plus, this technique offers a therapeutic option for patients who had none, due to significant comorbidities limiting open repair. Spinal cord injury is a major complication after complex aneurysm repair that dramatically affects patient's quality of life, even if technical success - aneurysm exclusion from circulation - has been achieved. Several strategies to prevent this terrible outcome have been developed, with remarkable success in narrowing down the number of patients who will suffer this complication. This comprehensive review covers how the standard of care for thoracoabdominal aortic aneurysms has evolved over time, how the understanding of spinal cord perfusion has changed in light of the collateral network concept, the risk factors associated with SCI, and details preventive strategies applied in current practice to lessen even further the frequency of spinal cord injury. Strategies covered go from the traditional adjuncts comprising hemodynamic control, neuroprotective drugs, neuromonitoring and cerebrospinal fluid drainage to emerging and innovative techniques such as near-infrared spectroscopy, two-step repair, minimally-invasive selective segmental artery coil-embolization, temporary aneurysm sac perfusion, and techniques for earlier pelvic and lower limb reperfusion.

Contemporary Single-Center Experience With Prophylactic Cerebrospinal Fluid Drainage for Thoracic Endovascular Aortic Repair in Patients at High Risk for Ischemic Spinal Cord Injury

To review rates of permanent paraplegia and lumbar drain-related complications in patients undergoing thoracic endovascular aortic repair (TEVAR) surgery with prophylactic cerebrospinal fluid (CSF) drainage at the authors' institution. Retrospective cohort study. Tertiary care, academic medical center. Patients who underwent TEVAR with a high risk for ischemic spinal cord injury and prophylactic lumbar CSF drainage over a 5-year period. None. One hundred and two patients underwent TEVAR with lumbar CSF drainage. Thirty-day mortality was 5.9%, and the rate of permanent paraplegia was 2%. Drain complications occurred in 4 (3.9%) patients, but no patient experienced permanent injury related to CSF drainage. Two patients in the cohort had complete resolution of paraplegia with increased CSF drainage and mean arterial blood pressure increases aimed to increase spinal cord perfusion pressure by 25%. A third patient experienced improvement in lower extremity strength but remained paraplegic, and a fourth patient demonstrated no improvement in symptoms. The 6 patients taking clopidogrel experienced no bleeding complications, and there were no apparent risk factors for bleeding in the 5 patients who had bloody drain output or in 1 patient who developed an epidural hematoma. Prophylactic CSF drainage was associated with low paraplegia and drain-related complication rates. These data further support the safety of prophylactic CSF drainage in patients undergoing TEVAR with a high risk for ischemic spinal cord injury.

Abstract 20935: Improving Spinal Cord Protection During the Frozen Elephant Trunk Technique: Effect of a Dedicated Neuroprotection Protocol

Introduction: The frozen elephant trunk (FET) technique may be complicated by a risk of spinal cord injury (SCI) which has been reported as high as 10%.Precise mechanisms responsible for SCI after FET are still unclear and so the best protection strategy to avoid it. Hypothesis: We aim to review our experience with a specific protocol developed to reduce the risk of SCI during open surgery of the descending aorta applied to patients operated with FET in order to increase spinal cord protection Methods: Spinal cord protection protocol included: 1.Careful preoperative planning to deploy of stent above the level of the 10th thoracic vertebra and preserving the patency of the left subclavian artery; 2.Postoperative management with goal directed therapy aimed to achieve mean systemic blood pressure between 85 and 105 mmHg, cardiac index &gt;2.4 l/min/m2, urine output &gt;1 ml/Kg/min, a base excess of 0±5, a pH&gt;7.3 and haemoglobin level &gt;10 g/dl; 3.Cerebrospinal fluid (CSF) drainage was used in 4 patients (5.8%) only Results: From April 2006 to December 2015 69 patients underwent aortic repair with the FET at our Institution.There were 31 males (51.7%). Median [IQR] age was 69 [59-75] years and median [IQR] Log EuroSCORE was 20.3 [13.9-36.2]. There were 19 (27.5%) reoperations. Operative times and outcomes are reported in Table 1. Conclusions: SCI remains the Achilles’ heel of the FET procedure.Elevated blood pressure in the preoperative period may reduce the risk of SCI by increasing the collateral network remodeling.Careful preoperarative planning and avoidance of sacrifice of all thoracic segmental arteries and preservation of left subclavian artery patency may reduce the risk of SCI maintaining good collateralization of the spinal cord perfusion network.Attention to all haemodynamic and metabolic parameters may avoid further ischemic insults to the spinal cord. CSF drainage may not be necessary in all cases of FET

Surgical ligation of spinal dural arteriovenous fistula.

Spinal dural arteriovenous fistulas (SDAVFs) are abnormal arteriovenous shunts between a radicular artery and the radicular vein, located in the dorsal surface of the dura sleeve, which drains in a retrograde manner into the coronal venous plexus of the spinal cord without an interposed capillary network. This result is a venous hypertension that reduces spinal cord perfusion and leads to ischemia and edema. Spontaneous resolution is extremely rare and, once symptomatic, the typical course is further progression with increased neurological impairment. Therefore, once a fistula is diagnosed, treatment is recommended. The fistula is placed at the level of intervertebral foramen and surgical ligation is performed through a laminectomy. After dural opening, the area is inspected, and the arterialized vein is identified and ligated. Laminectomy and arteriovenous fistula ligation is a safe and reliable approach for accessing and treating spinal dural arteriovenous fistulas.

Promising neuroprotective strategies for traumatic spinal cord injury with a focus on the differential effects among anatomical levels of injury.

Traumatic spinal cord injury (SCI) is a devastating condition of motor, sensory, and autonomic dysfunction. The significant cost associated with the management and lifetime care of patients with SCI also presents a major economic burden. For these reasons, there is a need to develop and translate strategies that can improve outcomes following SCI. Given the challenges in achieving regeneration of the injured spinal cord, neuroprotection has been at the forefront of clinical translation. Yet, despite many preclinical advances, there has been limited translation into the clinic apart from methylprednisolone (which remains controversial), hypertensive therapy to maintain spinal cord perfusion, and early decompressive surgery. While there are several factors related to the limited translational success, including the clinical and mechanistic heterogeneity of human SCI, the misalignment between animal models of SCI and clinical reality continues to be an important factor. Whereas most clinical cases are at the cervical level, only a small fraction of preclinical research is conducted in cervical models of SCI. Therefore, this review highlights the most promising neuroprotective and neural reparative therapeutic strategies undergoing clinical assessment, including riluzole, hypothermia, granulocyte colony-stimulating factor, glibenclamide, minocycline, Cethrin (VX-210), and anti-Nogo-A antibody, and emphasizes their efficacy in relation to the anatomical level of injury. Our hope is that more basic research will be conducted in clinically relevant cervical SCI models in order to expedite the transition of important laboratory discoveries into meaningful treatment options for patients with SCI.

Spinal Meninges and Their Role in Spinal Cord Injury: A Neuroanatomical Review.

Current recommendations support early surgical decompression and blood pressure augmentation after traumatic spinal cord injury (SCI). Elevated intraspinal pressure (ISP), however, has probably been underestimated in the pathophysiology of SCI. Recent studies provide some evidence that ISP measurements and durotomy may be beneficial for individuals suffering from SCI. Compression of the spinal cord against the meninges in SCI patients causes a "compartment-like" syndrome. In such cases, intentional durotomy with augmentative duroplasty to reduce ISP and improve spinal cord perfusion pressure (SCPP) may be indicated. Prior to performing these procedures routinely, profound knowledge of the spinal meninges is essential. Here, we provide an in-depth review of relevant literature along with neuroanatomical illustrations and imaging correlates.

Spotlight on the October 17 issue

#### Notable in Neurology This issue features an article that demonstrates spinal cord perfusion pressure maintenance above 50 mm Hg as a strong predictor of improved neurologic recovery following spinal cord injury and another that explores the course of Unverricht-Lundborg disease (EPM1) to identify the risk factors for severity. A featured Historical Neurology article reviews the observations of Jules Dejerine, which describe the clinical and pathologic presentation of acute motor axonal neuropathy decades earlier than previously thought. ### Pretreatment behavior and subsequent medication effects in childhood absence epilepsy![Graphic][1] In a randomized double-blind trial, children with newly diagnosed absence epilepsy had a high … [1]: /embed/inline-graphic-1.gif

Ruptured aneurysm of the artery of Adamkiewicz: is conservative management the standard of treatment in the current era?

Spinal aneurysms are rare lesions, and their natural history is not well known. In particular, aneurysms arising from the artery of Adamkiewicz (AA) are an extremely rare phenomenon, and given...

Spinal Ischemia in Thoracic Aortic Procedures: Impact of Radiculomedullary Artery Distribution

The aim of this study was to assess the influence of thoracic anterior radiculomedullary artery (tARMA) distribution on spinal cord perfusion in a thoracic aortic surgical model. Twenty-six pigs (34 ± 3 kg; study group, n= 20; sham group, n= 6) underwent ligation of the left subclavian artery and thoracic segmental arteries. End points were spinal cord perfusion pressure (SCPP), regional spinal cord blood flow (SCBF), and neurologic outcome with an observation time of 3 hours. tARMA distribution patterns tested for an effect on end points included (1) maximum distance between any 2 tARMAs within the treated aortic segment (0 or 1 segment = small-distance group; >1 segment= large-distance group) and (2) distance between the end of the treated aortic segment and the first distal tARMA (at the level of the distal simulated stent-graftend= group 0; gap of 1 or more segments= group ≥1). The number of tARMA ranged from 3 to 13 (mean, 8). In the large-distance group, SCBF dropped from 0.48 ± 0.16 mL/g/min to 0.3 ± 0.08 mL/g/min (p < 0.001). We observed no detectable SCBF drop in the small-distance group: 0.2 ± 0.05 mL/g/min at baseline to 0.23 ± 0.05 mL/g/min immediately after clamping (p= 0.147). SCBF increased from 0.201 ± 0.055 mL/g/min at baseline to 0.443 ± 0.051 mL/g/min at 3 hours postoperatively (p < 0.001) only in the small-distance group. We demonstrate experimental data showing that distribution patterns of tARMAs correlate with the degree of SCBF drop and insufficient reactive parenchymal hyperemia in aortic procedures. Individual ARMA distribution patterns along the treated aortic segment could help us predict the individual risk of spinal ischemia.

Translational Advances in the Management of Acute Spinal Cord Injury

Translational Advances in the Management of Acute Spinal Cord Injury

Spinal ischaemia after thoracic endovascular aortic repair with left subclavian artery sacrifice: is there a critical stent graft length?

Thoracic endovascular aortic repair (TEVAR) is used for treatment of thoracic aortic pathologies, but the covered stent graft can induce spinal ischaemia depending on the length used. The left subclavian artery contributes to spinal cord collateralization and is frequently occluded by the stent graft. Our objective was to investigate the impact of covered stent graft length on the risk of spinal ischaemia in the setting of left subclavian artery sacrifice. Twenty-six pigs (German country race, mean body weight 36 ± 4 kg) underwent simulated descending aortic TEVAR via left lateral thoracotomy, with left subclavian artery and thoracic segmental artery occlusion in normothermia. Animals were assigned to treatment groups according to simulated stent graft length: TEVAR to T8 (n = 4), TEVAR to T9 (n = 4), TEVAR to T10 (n = 4), TEVAR to T11 (n = 7) and TEVAR to T12 (n = 1) and a sham group (n = 6). End points included spinal cord perfusion pressure, cerebrospinal fluid pressure and spinal cord blood flow using fluorescent microspheres. There were no group differences in spinal cord perfusion pressure drop or in spinal cord perfusion pressure regeneration potential at 3 h after the procedure: from a baseline average of 75 mmHg (95% confidence interval 71-83 mmHg) to 73 mmHg (67-75 mmHg) at 3 h in Group T10 versus from a baseline average of 67 mmHg (95% CI 50-81 mmHg) to 65 mmHg (95% confidence interval 48-81 mmHg) in Group T8. There were no differences in the spinal cord blood flow courses over time in the different groups nor was there any difference in cerebrospinal fluid pressure levels and cerebrospinal fluid pressure dynamics between groups. However, we did observe local blood flow distribution to the spinal cord that was inhomogeneous depending on the distance between the simulated stent graft end and the first thoracic anterior radiculomedullary artery. The risk of spinal ischaemia after serial segmental artery occlusion does not depend on the distal extent of the aortic repair alone. Future attempts to allow patient risk stratification for spinal ischaemia need to focus on anterior radiculomedullary artery anatomy together with the extent of planned aortic repair.

Anesthetic management of spontaneous cervical epidural hematoma during pregnancy: a case report

BackgroundSpontaneous spinal epidural hematoma during pregnancy is a quite rare event requiring emergent decompressive surgery in the majority of cases to prevent permanent neurological damage. Therefore, there is little data in the literature regarding anesthetic management of cervical localization during pregnancy. The potential for difficult airway management with the patient under general anesthesia is one of the major concerns that needs to be addressed to prevent further cord compression. Anesthetic management should also include measures to maintain the mean arterial pressure to improve spinal cord perfusion. Furthermore, spine surgery in pregnant patients needs special consideration in terms of positioning and in the postoperative period.Case presentationWe present a case of a 35-year-old white woman at 21 weeks of gestation with a spontaneous cervical epidural hematoma. Fiberoptic bronchoscope-guided nasal intubation was a safe option to ensure a higher rate of successful endotracheal intubation while minimizing the risk of aggravating the injury. Her care posed other multiples challenges that required a multidisciplinary team approach.ConclusionsThe case of our patient serves as a reminder of this rare condition and its implications regarding anesthesia.