Treatment Of Spinal Cord Ischemia Research Articles

Spinal cord ischemia - from diagnosis to treatment.

The aim of the article is to outline the frequency of the occurrence, course, diagnosis and possible treatment of spinal cord ischemia (SCI) on the basis of a literature overview and to raise awareness of this rare yet devastating condition. SCI, when compared to cerebral stroke, is a relatively rare disease, being diagnosed 100 times less often. Our knowledge as to its root causes, proper treatment for it and long-term prognosis is still inconclusive. Magnetic resonance imaging with diffusion- weighted contrast is a main tool with which to confirm SCI and rule out a broad spectrum of possible alternative diagnoses. SCI is a condition in which prompt recognition, accurate diagnostic steps, and reperfusion therapy are essential to ensure a desirable functional outcome and reduce mortality and disability. Although there are no specific guidelines regarding treatment, the administration of rt-PA might be an effective therapy for acute ischemic stroke, preventing permanent spinal dysfunction. In surgical causes close cooperation between a neurologist and a neurosurgeon is necessary to provide combined appropriate management promptly. Due to the relative rarity of SCI, multi-center studies of ischemia of the spinal cord and its treatment would be advisable in neurological practice to enhance current knowledge. A rapid diagnosis is crucial for appropriate care and desirable long-term outcomes.

Con: Lumbar Drains Should Routinely Be Placed by a Landmark Approach and Not by Fluoroscopic Guidance for Elective Thoracic Aortic Repairs

SPINAL CORD ISCHEMIA (SCI) after thoracoabdominal aortic repair is a well-known complication of both open and endovascular surgery, with reported rates as high as 5%-to-21% after open repair. 1 Gravereaux EC Faries PL Burks JA et al. Risk of spinal cord ischemia after endograft repair of thoracic aortic aneurysm. Jour of Vasc Surg. 2001; 34: 997-1003 Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar Resultant morbidity, including paraparesis and paraplegia, are devastating, and a fair amount of research has gone into developing strategies for mitigating SCI-related complications. Cerebrospinal fluid drainage (CSFD) with the placement of lumbar drains (LDs) is considered the current recommendation for both prevention and treatment of SCI in high-risk patients. 2 Coselli JS LeMaire SA Koksoy C et al. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg. 2002; 35: 631-639 Abstract Full Text Full Text PDF PubMed Scopus (520) Google Scholar ,3 Hiratzka LF Bakris GL Beckman JA et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010; 121: e266-e369 Crossref PubMed Scopus (1914) Google Scholar While there is some controversy over the utility of CSFD for endovascular repairs, it is still a widely accepted practice that is performed frequently for patients at high risk of developing SCI postrepair. 4 Isaak RS Furman W. Con: Patients at risk for spinal cord ischemia after thoracic endovascular aortic repairs should not receive prophylactic cerebrospinal fluid drainage. J Cardiothorac Vasc Anesth. 2015; 29: 1381-1383 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Protocols regarding the placement of LDs can vary by institution, whereby some centers may routinely use imaging guidance for the procedure. In this review, the authors examine the specifics of using fluoroscopic guidance for the preoperative placement of LDs in patients who are at a high risk of developing SCI after thoracoabdominal aortic repair. It is the authors’ belief that the universal use of fluoroscopic guidance is unnecessary, potentially harmful, confers additional expense, and is unsupported by the current body of evidence.

Implementation of a treatment algorithm to decrease incidence of paralysis post endovascular thoracoabdominal aorta repair

Spinal cord ischemia (SCI) is a rare but devastating complication following aortic repair. Despite improvements in operative management and critical care of aortic disease patients, SCI remains one of the most serious and common complications after these procedures. Early recognition and rescue interventions can augment the outcome and reduce the morbidity or avoid permanent dysfunction. This is a single institution experience of creating an evidence-based algorithm for the treatment of SCI in patients after thoracoabdominal endovascular aortic repair (TEVAR). We implemented an evidence-based treatment algorithm for the management of acute SCI after TEVAR. A total of 131 TEVAR cases were reviewed, 59 cases preimplementation, and 72 cases postimplementation of an SCI treatment algorithm. Lower extremity motor and/or sensory deficits were identified in 5.1% of preimplementation and 4.2% of postimplementation cases. SCI treatment interventions included increasing the mean arterial pressure (MAP) (66% pre and 100% post), placing lumbar drain (33% pre and 33% post), performing carotid subclavian bypass (33% pre and 33% post), initiating naloxone drip (66% pre and 100% post), and administering glipizide (0% pre and 100% post, P<.05). Long-term paralysis occurred in 66% of preimplementation and 0% of postimplementation cases. By creating and implementing an SCI treatment algorithm we reduced both, time to detection and time to effective treatment of SCI and significantly improved our patients' neurological outcomes.

The spinal catheter in aortic surgery : Implications for anesthesia

During surgical repair of aortic pathologies (e.g. dissection, aneurysms), cross-clamping of the aorta or overstenting of critical segmental arteries can lead to ischemia- and edema-related spinal cord damage with subsequent paraplegia. By regulating cerebrospinal fluid pressure, the spinal catheter is an effective method for prophylaxis and treatment of spinal cord ischemia. Due to the high complication rate of the spinal catheter adetailed risk-benefit assessment is obligatory: besides cerebrospinal fluid leakage, postpuncture headaches and local infections, feared complications, such as intracranial bleeding, meningitis and neuraxial hematomas can also occur, sometimes with asignificant latent period after termination of the procedure. Adequate training of personnel in the perioperative handling of spinal catheters and meticulous adherence to drainage parameters are important components for increasing procedural safety. This is particularly true since the clinical aspects of catheter-associated complications only slightly differ from that of ischemic spinal cord injury.

Back Pain in Rare Diseases: A Comparison of Neck and Back Pain between Spinal Cord Ischemia and Spinal Dural Arteriovenous Fistula.

Neck and back pain may be noted like a first symptom in rare diseases: spinal cord ischemia and spinal dural arteriovenous fistula (SDAVF). Spinal cord ischemia is a rarer pathology, compared with cerebral ischemia, yet the morbidity and mortality are comparable in both cases; furthermore, classifying the acute loss of function in the spine, encountered in spinal cord ischemia as an important neurological entity. SDAVF presents the same clinical symptoms as spinal cord ischemia, but even though it has a progressive character, the impact in the quality of patients’ lives being equally as important. Between August 2012–August 2017 we admitted through the hospital emergency department 21 patients with spinal cord ischemia and 11 patients with SDAVF (only self-casuistry). Demographic (age, gender), clinical, imagistic (Magnetic Resonance Angiography, Magnetic Resonance Imaging), paraclinical data as well as history, time to diagnosis, the visual analogue scale for pain (VAS score), risk factors, surgical and medical treatment, evolution, neurorehabilitation, were all used to compare the two lots of patients. The aim of this study was to observe potential differences in the demographics, symptomatology, VAS scores and treatment in comparison for spinal cord ischemia and SDAVF, to facilitate the further recognition and management in these diseases. In group A we have 21 patients with spinal cord ischemia (14 females, 7 males). The median age was 41.3 years (range 19–64). The median time to diagnosis was 7 h. The most frequent symptoms were acute neck or back pain at onset (100%), motor deficits (95.24%), sensory loss (85.72%), and sphincters problems (90.48%). The most common location was the lumbosacral spine (14 cases; 66.67%; p-value = 0.03) for spinal cord ischemia and the thoracic spine (7 cases, 63.64%; p-value = 0.065) for SDAVF. The treatment of spinal cord ischemia was medical. In group B we included 11 patients (6 females, 5 males). The median age was 52.6 years (range 28–74). The median time to diagnosis was 3 months (range 2 days–14 months). Patients have progressive symptoms: neck or back pain (100%), gait disturbances (100%) and abnormalities of micturition (100%). The treatment of SDAVF was surgical occlusion of fistula. The proportion of severe VAS score (7–10) in patients with spinal cord ischemia was significantly higher than that in patients with SDAVF (100% vs. 18, 19%; p-value = 0.051). Taking into consideration that the usual findings and diagnosis of spinal cord ischemia and SDAVF are still challenging for neurologists and in some cases the difficulties are related to technical limitations, we consider these entities to be rare but very important for the life of our patients. Patients were grouped into spinal cord ischemia and SDAVF status and those with acute or chronic pain conditions, measured by the VAS score. Patients with spinal cord ischemia develop acute neurological symptoms. They are much younger than the patients with SDAVF and the recovery rate is higher. Patients with SDAVF develop a progressive myelopathy and they suffer considerable neurological deficits. Imaging the lesions with MR angiography or MRI, we can confirm the diagnosis.

Trends in Use of Cerebrospinal Fluid Drains and Outcomes Related to Spinal Cord Ischemia in the Vascular Quality Initiative

Spinal cord ischemia (SCI) is a feared complication of aortic repair. Given that cerebrospinal fluid (CSF) drain placement has some inherent risk but also known benefit, a better understanding of CSF drain practices and utilization in prevention and treatment of SCI is needed to guide use. We used the Vascular Quality Initiative (VQI) database to identify trends in CSF drain use and SCI rates in thoracic endovascular aortic repair (TEVAR) and complex branched-fenestrated endovascular aneurysm repair (cEVAR).

Outcomes of a Spinal Drain and Intraoperative Neurophysiologic Monitoring Protocol in Thoracic Endovascular Aortic Repair

Adjuncts for early detection and treatment of spinal cord ischemia (SCI) in thoracic aortic surgery are supported by robust clinical experience in open repair. The utility of cerebrospinal fluid (CSF) drainage and neurophysiologic monitoring (NPM) in thoracic endovascular aortic repair (TEVAR) is less clear. The purpose of this investigation is to determine the influence of a selective institutional spinal cord protection protocol using prophylactic NPM and CSF on outcomes for standard TEVAR. Patients undergoing standard TEVAR entered into a prospectively maintained database from a single institution from 2007 to 2016 were retrospectively reviewed. Preoperative characteristics, aneurysm extent, and etiology were reviewed. Utilization of CSF drains including volume of fluid removed, duration of drainage, and catheter-related complications were collected. NPM data were reviewed to determine the influence on intraoperative management. Exact logistic regression was used to identify independent predictors of SCI. Of 223 patients undergoing TEVAR, 130 met inclusion criteria for the study. CSF drains were used in 71 patients (54.6%), and 56 of 130 (43%) had NPM. SCI occurred in 7 patients (5.4%), of whom 5 had partial or complete recovery. Median time to symptoms of SCI was delayed in all cases (median 52hr, range 8-312), and none of the 4 of 7 patients with adjunct NPM demonstrated intraoperative changes. Intraoperative changes in NPM occurred in 26 (46%), and represented unilateral leg ischemia in all but 2 cases. In both patients, changes consistent with SCI were associated with intraoperative hypotension and resolved with blood pressure augmentation. Neither patient developed postoperative SCI. Median length of stay (22 vs. 9days, P=0.012), operative room time (262 vs. 209, P=0.040), and perioperative mortality (28.6% vs. 4.1%, P=0.046) were significantly higher for patients with SCI versus those without. Length of aortic coverage was found to be the sole independent predictor of SCI (odds ratio 8.2, P=0.026). Complications related to CSF drainage occurred in 4 patients (5.6%) with major complications occurring in 2 patients (2.8%), including 1 with an intrathecal hematoma and permanent bilateral paraparesis. Selective use of prophylactic CSF drainage in TEVAR was associated with moderate risk and questionable benefit. The use of neurophysiological monitoring allowed for early detection and treatment of spinal ischemia, but its utility is limited by logistical factors and to the minority of patients with intraoperative spinal ischemic events.

Spinal Cord Infarcts: Risk Factors, Management, and Prognosis.

There are no standard guidelines for treatment of spinal cord ischemia due to how rare it is and the diverse etiology and presentations involved. In addition, to date, there have been no large clinical trials examining ideal pharmacologic treatment options for spinal cord infarct. In our practice, we rely on hemodynamic augmentation initiated as soon as possible. Otherwise, treatment is usually geared towards the etiology of spinal cord ischemia. For instance, spinal cord ischemia occurring after aortic aneurysmal repair may improve with CSF drainage through a lumbar catheter in the periprocedural setting. Vertebral artery dissection should be treated with antithrombotics. If no clear etiology is found and there is evidence of atherosclerosis in other vascular beds, then management is focused on risk factor modification with blood pressure and glucose control, statins, and antithrombotics.

Protocol for prevention of spinal cord ischemia after thoracoabdominal aortic surgery.

This manuscript was written to present a systemic protocol for the prevention, early detection, and treatment of spinal cord ischemia following open and endovascular thoracoabdominal aortic operations. This protocol was a collaborative effort between surgeons, anesthesiologists and intensivists. It was implemented at our institution in November 2007. Nurses are trained to prevent, rapidly detect and ultimately aid in the treatment of spinal cord ischemia. Implementation of this protocol has aided in prevention, detection and treatment of spinal cord ischemia in patients after open and endovascular thoracoabdominal aortic operations. Standardized care and reliance on trained nursing staff to monitor for symptoms following thoracoabdominal aortic operations are safe and aid in the rapid detection, treatment and reversal of spinal cord ischemia.

Microarray expression profile of genes in rats subjected to spinal cord ischemia

ObjectiveSpinal cord ischemia is a common disease with a high mortality and morbidity. It will induce the motor and sensory deficits, which bring heavy burden to the patient, family and society. However, the underlying molecular mechanism remains to be elucidated and the treatment is far from satisfaction. How to search the key moleculares from multiple genes, after spinal cord ischemia may provide the basic orientation for gene therapy in future clinic trial.MethodsHere, sixteen male rats were employed and randomly divided into the sham and spinal cord ischemia group. Aorta blocking was performed to establish the spinal cord ischmic model. Microarray technique was applied to select the differentially expressed genes between the spinal cord ischemia and sham group in spinal cord tissues at 72 h post operation. Gene ontology analysis, including biological process, cellular component and molecular function, and Kyoto Encyclopedia of Genes and Genomes (KEGG). Genomes were adopted to analyze the function and pathway of the differentially expressed genes following spinal cord ischemia.ResultsSpinal cord ischemic model was successfully established indicated by disappearing of the caudal pulse. Microassay analysis showed that there were 3984 up‐regulated genes and 3513 down‐regulated genes in spinal cord after ischemia. Of these, neurodegeneration, oxidativve, inflamation have been involved, and various functions and pathways, such as signal pathway of ribosome and oxidative phosphorylation pathway have been involved in these differentially expressed genes.ConclusionOur results revealed a network of multiple genes involving in neurodegeneration, oxidative, and inflammation exerts main influnce in the spinal cord after ischemia. These findings will provide potentially novel understanding for the treatment of spinal cord ischemia.

Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair

The purpose of this study was to assess the incidence, risk factors, and clinical manifestations of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). A retrospective review of a prospectively collected database was performed for all patients undergoing TEVAR at a single academic institution between July 2002 and June 2010. Preoperative demographics, procedure-related variables, and clinical details related to SCI were examined. Logistic regression analysis was performed to identify risk factors for the development of SCI. Of the 424 patients who underwent TEVAR during the study period, 12 patients (2.8%) developed SCI. Mean age of this cohort with SCI was 69.6 years (range, 44-84 years), and 7 were women. One-half of these patients had prior open or endovascular aortic repair. Indication for surgery was either degenerative aneurysm (n = 8) or dissection (n = 4). Six TEVARs were performed electively, with the remaining done either urgently or emergently due to contained rupture (n = 2), dissection with malperfusion (n = 2), or severe back pain (n = 2). All 12 patients underwent extent C endovascular coverage. Multivariate regression analysis demonstrated chronic renal insufficiency to be independently associated with SCI (odds ratio [OR], 4.39; 95% confidence interval [CI], 1.2-16.6; P = .029). Onset of SCI occurred at a median of 10.6 hours (range, 0-229 hours) postprocedure and was delayed in 83% (n = 10) of patients. Clinical manifestations of SCI included lower extremity paraparesis in 9 patients and paraplegia in 3 patients. At SCI onset, average mean arterial pressure (MAP) and lumbar cerebrospinal fluid (CSF) pressure was 77 mm Hg and 10 mm Hg, respectively. Therapeutic interventions increased blood pressure to a significantly higher average MAP of 99 mm Hg (P = .001) and decreased lumbar CSF pressure to a mean of 7 mm Hg (P = .30) at the time of neurologic recovery. Thirty-day mortality was 8% (1 of 12 patients). The single patient who expired, never recovered any lower extremity neurologic function. All patients surviving to discharge experienced either complete (n = 9) or incomplete (n = 2) neurologic recovery. At mean follow-up of 49 months, 7 of 9 patients currently alive continued to exhibit complete, sustained neurologic recovery. Spinal cord ischemia after TEVAR is an uncommon, but important complication. Preoperative renal insufficiency was identified as a risk factor for the development of SCI. Early detection and treatment of SCI with blood pressure augmentation alone or in combination with CSF drainage was effective in most patients, with the majority achieving complete, long-term neurologic recovery.

Paraplegia prevention branches: A new adjunct for preventing or treating spinal cord injury after endovascular repair of thoracoabdominal aneurysms

In this report, we describe a technique that could potentially be used for both prevention and treatment of spinal cord ischemia (SCI) in endovascular repair of thoracoabdominal aneurysms. This technique involves using a specially designed endograft with side branches (paraplegia prevention branches [PPBs]), which are left patent to perfuse the aneurysmal sac and any associated lumbar or intercostal arteries in the early postoperative period. The use of PPBs with this technique is feasible and allows for a temporary controlled endoleak that may be useful for preventing or reversing spinal cord injury. This technique may be considered as an adjunct to the more standard perioperative physiological manipulations such as permissive hypertension and spinal fluid drainage.

Multidisciplinary Approach to Prevent Spinal Cord Ischemia After Thoracic Endovascular Aneurysm Repair for Distal Descending Aorta

This article discusses the multidisciplinary approach to prevent spinal cord ischemia (SCI) with reference to the incidence of SCI after thoracic endovascular aneurysm repair (TEVAR) associated with closure of the intercostal-lumbar artery that supplies the Adamkiewicz artery (ICA-AKA). We reviewed 60 patients [49 men, 57 to 89 years old] who underwent TEVAR (TAG [W. L. Gore & Associates, Flagstaff, AZ] 42; the Matsui-Kitamura (Kanazawa, Japan) 10; Talent [Medtronic Inc, Santa Rosa, CA] 5; TAG and Talent 3) for part of or the entire distal descending aorta between T7 and L2. These patients had frequently undergone aortic surgeries: ascending aorta (4), aortic arch (25), descending aorta (4), thoracoabdominal aorta (3), and abdominal aorta (19). The multidisciplinary approach consists of identification of the ICA-AKA by magnetic resonance angiography or computed tomographic angiography to avoid unnecessary coverage of the ICA-AKA, in combination with monitoring of motor evoked potentials, augmentation of mean arterial pressure (> 80 mm Hg), and cerebrospinal fluid drainage. Spinal cord ischemia occurred in 4 patients and patent ICA-AKAs were covered in 3 of them. The overall incidence of SCI was 6.7% and 9.4% in the group of 32 patients whose patent ICA-AKAs were covered by TEVAR. After treatment for SCI, 3 patients regained full ambulatory ability. Significant risk factors were identified as the artificial graft at the proximal landing zone, the number of covered zones (>8), the length of aortic coverage (>250 or >300 mm), and the length of the uncovered distal aorta (<60 mm). A multidisciplinary approach is essential to prevent SCI after TEVAR for the distal descending aorta. This approach includes the preservation of patent ICA-AKAs after their identification, early diagnosis of SCI during TEVAR by monitoring motor evoked potentials, and prophylaxis and treatment of SCI by increasing mean arterial pressure to at least 80 mm Hg and performing cerebrospinal fluid drainage.

Spinal cord protection and thoracic aortic surgery

Spinal cord ischemia remains an important complication of open surgical and endovascular stent graft repair of thoracic and thoracoabdominal aortic aneurysm despite advances in operative technique. Identification of risk factors and interventions to prevent and treat spinal cord ischemia has the potential to prevent spinal cord infarction and the morbidity and mortality associated with paraplegia. Risk factors for spinal cord ischemia are aneurysm extent, open surgical repair, prior distal aortic operations, and perioperative hypotension. Augmenting spinal cord perfusion by increasing arterial pressure, lumbar cerebrospinal fluid drainage, and reattachment of segmental arteries are effective for the treatment of spinal cord ischemia. Early detection of spinal cord ischemia by intraoperative neurophysiologic monitoring and postoperative neurological examination is important to enable immediate treatment to prevent permanent paraplegia. Permanent paraplegia after thoracic and thoracoabdominal aortic aneurysm repair can be prevented in many high-risk patients by early detection and immediate treatment of spinal cord ischemia before it evolves to infarction. The mortality and morbidity associated with permanent paraplegia justifies the risks and uncertainties associated with established therapeutic interventions.

The Treatment of Spinal Cord Ischemia Following Thoracic Endovascular Aortic Repair

Thoracic endovascular aortic repair (TEVAR) is a promising alternative to the traditional open surgical approach, though spinal cord ischemia remains a challenging complication. Spinal cord ischemia has been treated using lumbar cerebral spinal fluid (CSF) drainage. We report a case of delayed spinal cord ischemia that was successfully treated with vasopressor therapy alone, supporting aggressive blood pressure augmentation as a primary intervention to increase spinal cord perfusion. The pathophysiology of spinal cord ischemia after TEVAR is presented along with our treatment protocol.

Preliminary results of deferoxamine and L1 treatment of spinal cord ischemia

time course of the ACT over this period of heparin removal. The ACT after completion of this treatment was 160 seconds, whereas the baseline ACT before CPB was 192 seconds. Other coagulation studies, however, showed a persistent coagulopathy that was corrected over the hext 4 hours with infusion of fresh frozen plasma and cryoprecipitate. She was also treated with epsilon aminocaproic acid to correct abnormal fibrinolysis. The chest tube output was 300 to 400 ml/hr for the first 4 hours after heparin removal but diminished to an insignificant level, and she did well thereafter. No alternatives to protamine for heparin reversal are currently available. Although platelet factor 4 has been shown to be an effective neutralizer of heparin, 2 it is in the early stages of investigation and will likely not be available in the near future. The Heparin Removal Device uses a plasmapheresis filter that is widely used clinically but has a resin added to the plasma compartment that binds and removes heparin. This approach to heparin removal has great potential merit as an alternative to protamine. It awaits a phase 1 clinical trial after FDA review and approval as an investigational device.