Adjunctive hyperbaric oxygen therapy for spinal cord ischemia after complex aortic repair.

OBJECTIVE: Spinal cord ischemia (SCI) with paraplegia or paraparesis is a devastating complication of complex aortic repair (CAR). Treatment includes cerebrospinal fluid drainage, maintenance of hemoglobin concentration (>10 g/L), and elevating mean arterial blood pressure. Animal and human case series have reported improvements in SCI outcomes with hyperbaric oxygen therapy (HBOT). We reviewed our center's experience with HBOT as a rescue treatment for spinal cord ischemia post-CAR in addition to standard treatment. METHODS: A retrospective review of the University Health Network's Hyperbaric Medicine Unit treatment database identified HBOT sessions for patients with SCI post-CAR between January 2013 and June 2021. Mean estimates of overall motor function scores were determined for postoperative, pre-HBOT, post-HBOT (within 4 hours of the final HBOT session), and at the final assessment (last available in-hospital evaluation) using a linear mixed model. A subgroup analysis compared the mean estimates of overall motor function scores between improvement and non-improvement groups at given timepoints. Improvement of motor function was defined as either a ≥2 point increase in overall muscle function score in patients with paraparesis or an upward change in motor deficit categorization (para/monoplegia, paraparesis, and no deficit). Subgroup analysis was performed by stratifying by improvement or non-improvement of motor function from pre-HBOT to final evaluation. RESULTS: Thirty patients were treated for SCI. Pre-HBOT, the motor deficit categorization was 10 paraplegia, three monoplegia, 16 paraparesis, and one unable to assess. At the final assessment, 14 patients demonstrated variable degrees of motor function improvement; eight patients demonstrated full motor function recovery. Seven of the 10 patients with paraplegia remained paraplegic despite HBOT. The estimated mean of overall muscle function score for pre-HBOT was 16.6 ± 2.9 (95% confidence interval [CI], 10.9-22.3) and for final assessment was 23.4 ± 2.9 (95% CI, 17.7-29.1). The estimated mean difference between pre-HBOT and final assessment overall muscle function score was 6.7 ± 3.1 (95% CI, 0.6-16.1). The estimated mean difference of the overall muscle function score between pre-HBOT and final assessment for the improved group was 16.6 ± 3.5 (95% CI, 7.5-25.7) vs -4.9 ± 4.2 (95% CI, -16.0 to 6.2) for the non-improved group. CONCLUSIONS: HBOT, in addition to standard treatment, may potentially improve recovery in spinal cord function following SCI post-CAR. However, the potential benefits of HBOT are not equally distributed among subgroups.

Perioperative Blood Transfusion Is Associated with Worse 30-Day Mortality and Complications After Thoracic Endovascular Aortic Repair.

BACKGROUND: It is not uncommon for patients requiring vascular surgery, and in particular aortic surgery, to have increased requirements for blood transfusion. However, studies examining the effects of perioperative transfusion for thoracic endovascular aortic repair (TEVAR) are limited. Using large multicenter data, we aimed to study the impact of perioperative blood transfusion on 30-day mortality and complications after TEVAR. METHODS: A total of 9,263 patients who underwent TEVAR were included in this retrospective study from the multicenter Vascular Quality Initiative cohort spanning 2010-2022. We excluded patients who were post-traumatic, anemic (World Health Organization criteria: hemoglobin < 12 g/dl and < 13 g/dl for females and males respectively), who underwent open conversions or presented with ruptured aneurysms. Primary outcomes were 30-day mortality and stroke. Secondary outcomes were postop congestive heart failure (CHF), respiratory complications, spinal cord ischemia (SCI), myocardial infarction (MI) and any postop complications (composite variable). Poisson regression with robust variance was performed to determine the risk of post op outcomes comparing patients who received red blood cells (RBCs) to those who did not. RESULTS: Comparing patients without any transfusion (n = 8,223), perioperative transfusion of 1-3 units (n = 735) was associated with 3-fold increased risk of 30-day mortality (adjusted relative risk [aRR] 3.30, 95% confidence interval [CI] 2.39,4.57, P < 0.001), almost 2-fold increased risk of stroke (aRR 1.98, 95% CI 1.24,3.15, P = 0.004), 2.7-fold increased risk of SCI (aRR 2.66, 95% CI 1.87-3.77, P < 0.001), 3-fold increased risk of MI (aRR 3.40, 95% CI 2.30, 5.03, P < 0.001), 2-fold increased risk of CHF (aRR 2.04, 95% CI 1.09, 3.83, P = 0.03), 3.5-fold increased risk of respiratory complications (aRR 3.49, 95% CI 2.67, 4.56, P < 0.001), and 2-fold increased risk of any postop complication (aRR 2.36, 95% CI 2.04, 2.73, P < 0.001). These effects were even higher in patients transfused 4 or more units (n = 305) than seen in the effects seen in those transfused 1-3 units; comparing each group to patients who received none. CONCLUSIONS: In hemodynamically stable patients undergoing TEVAR for nonemergent/emergent and nontraumatic indications, transfusion of any amount perioperatively is associated with worse 30-day mortality, stroke, SCI, MI, CHF, and respiratory complications. A conservative transfusion approach and multidisciplinary care to identify complications and rescue TEVAR patients who receive any amount of RBCs perioperatively might help improve outcomes. Future studies to understand the mechanisms of outcomes for transfused patients are needed.

Protective Effect of Mild Hypothermia on Spinal Cord Ischemia-Induced Delayed Paralysis and Spinal Cord Injury.

To explore the mechanism regarding the regulation of spinal cord ischemia (SCI) in rats by mild hypothermia. A SCI rat model was established through aorta occlusion, and in some cases, the rats were intervened with mild hypothermia, after which motor function, microglia activation, and M1/M2 polarization in rats were measured. Also, the expression of inflammatory cytokines (IL-1ß, IL-6 and TNF-α) and neuronal apoptosis were examined. Lipopolysaccharide (LPS)-induced M1 microglia and IL-4-induced M2 microglia were intrathecally injected into rats to evaluate the effect of microglial polarization on SCI. In in vitro experiments, primary microglial cells were treated under hypothermic condition, in which M1/M2 polarization and microglia apoptosis, the levels of iNOS, CD86, CD206, Arg-1 and inflammatory cytokines were assessed. Western blot analysis detected the activation of the TLR4/NF-κB pathway to investigate the role of this pathway in M1/M2 polarization. SCI treatment impaired motor function, induced higher M1 microglia proportion, and increased the levels of pro-inflammatory cytokines in rats, and mild hypothermic treatment attenuated these trends. Moreover, injection of M1 microglia increased M1 microglia proportion and increased the levels of pro-inflammatory cytokines, while injection of M2 microglia induced the reverse results, i.e. decreased M1 microglia proportion and reduced pro-inflammatory cytokine levels. In LPS-induced microglial cells, mild hypothermia treatment increased M2 microglia proportion and decreased pro-inflammatory cytokine levels, relative to normothermia. Mild hypothermia inactivated the TLR4/NF-κB pathway in LPS-treated microglia. TLR4 overexpression reversed the function of mild hypothermia in LPS-stimulated microglia, and under normal condition, TLR4/NF-κB pathway suppressed microglial M2 polarization. Mild hypothermia inhibits TLR4/NF-κB pathway and promotes microglial M2 polarization, thus attenuating SCI-induced injury and inflammation.

The Neuroprotective Mechanism of Spinal Cord Stimulation in Spinal Cord Ischemia/Reperfusion Injury.

BACKGROUND: Spinal cord ischemia/reperfusion (I/R) injury following thoracoabdominal aneurysm surgery can lead to severe lower limb neurologic defect. The preliminary result of our study suggested that spinal cord stimulation (SCS) postconditioning effectively protected spinal cord from I/R injury on rabbits. But the mechanism is unknown. In this study, we further investigated the mechanism of SCS postconditioning. METHOD: New Zealand white rabbits were randomly divided into sham, I/R, I/R + 2 Hz SCS, and I/R + 50 Hz SCS group (n = 24/group). Transient spinal cord ischemia was induced by infrarenal aortic balloon occlusion and performed on all rabbits except rabbits of sham group. Rabbits of I/R group received no further intervention. Rabbits of I/R + 2 Hz SCS and I/R + 50 Hz SCS group received 2 Hz or 50 Hz SCS for 30 min at the onset of reperfusion and then daily. The expression of Akt (serine-threonine kinase)/p-Akt, STAT3 (signal transducer and activator of transcription 3)/p-STAT3 and GSK-3ß (glycogen synthase kinase)/p-GSK-3ß of spinal cord were measured by Western blot analysis at 8 h, 1 day, 3 day, and 7 day of reperfusion. RESULT: The Akt expressions of sham, I/R, I/R + 2 Hz SCS, and I/R + 50 Hz SCS group were not significantly different at all prescribed time points, while the p-Akt expression of I/R + 2 Hz SCS group was significantly higher than that of I/R group and sham group at all prescribed time points; The STAT3 and p-STAT3 expression of I/R, I/R + 2 Hz SCS, and I/R + 50 Hz SCS group were not significantly different at all prescribed time points except that at 1day of reperfusion the p-STAT3 expression of I/R + 50 Hz SCS group was significantly lower than I/R group. The GSK-3ß and p-GSK-3ß expressions of I/R, I/R + 2 Hz SCS and I/R + 50 Hz SCS group were not significantly different at all prescribed time points. CONCLUSION: The neuroprotective effect of 2 Hz SCS postconditioning in spinal cord I/R injury is related to Akt activation but not regulation of STAT3 and GSK-3ß phosphorylation.

Isolated Infarctions of the Conus Medullaris: Clinical Features and Outcomes.

OBJECTIVE: This study aims to describe the clinical features and outcomes of patients with isolated infarctions of the conus medullaris, and to identify factors associated with poor functional outcomes. MATERIALS AND METHODS: We performed a systematic review and retrospective analysis on the clinical characteristics and outcomes of patients with isolated conus medullaris infarctions reported in literature over the past 30 years. RESULTS: We analyzed a total of 19 cases; 18 identified in literature from January 1991 to June 2021, together with our patient. Their median age was 56 years (range 28-79), with twice as many females as males. Pain was prominent at onset (15/19, 79%), only a third had vascular risk factors (7/19, 37%), and half had no significant preceding activities or events (9/19, 47%). Almost all experienced paraplegia or paraparesis (16/19, 84%), in which upper motor neuron features were rare (3/19, 16%). The underlying cause was unknown in half (10/19, 53%). Functional outcomes appeared fair, with nearly half being capable of unassisted ambulation (9/11, 82%). Patients with vascular risk factors (67% vs 13%, p = 0.024) or with identified underlying causes (78% vs 13%, p = 0.007) were less likely to walk unassisted. CONCLUSION: Isolated conus medullaris but should be considered in patients with acute cauda equina syndrome, especially in females. Patients with vascular risk factors, or with known causes of infarction, are less likely to walk unassisted. DWI sequences should be included in conventional MRI sequences when evaluating patients with acute cauda equina syndrome.

Incidence, predictors, and outcomes of spinal cord ischemia in elective complex endovascular aortic repair: An analysis of health insurance claims.

OBJECTIVE: This study aimed to determine predictors and outcomes associated with spinal cord ischemia (SCI) after elective fenestrated or branched endovascular aneurysm repair (F/BEVAR) of thoracoabdominal aortic aneurysm (TAAA), abdominal aortic aneurysm (AAA), or aortic dissection. METHODS: Health insurance claims data of Germany's third largest insurance provider, DAK-Gesundheit, were used to investigate SCI in elective F/BEVAR performed between 2008 and 2017. The International Classification of Diseases and German Operation and Procedure Classification System were used. We stratified the results into F/BEVAR with one or two (AAA) vs three or more (TAAA) fenestrations or branches. RESULTS: A total of 877 patients (18.9% female; 5.8% with SCI) matching the inclusion criteria were identified during the study period. SCI occurred more often after F/BEVAR of TAAA vs AAA (10.7% vs 3.0%; P < .001). SCI was associated with female sex in the AAA group (odds ratio, 3.87; 95% confidence interval [CI], 1.25-11.15; P = .014) and with cardiac arrhythmias in the TAAA group (odds ratio, 2.98; 95% CI, 1.24-7.06; P = .013). Compared with patients without SCI, SCI patients were more likely to suffer from drug use disorders (eg, opioids, cannabinoids, sedatives) in the TAAA group (17.6% vs 2.1%; P < .05). After F/BEVAR of TAAA, the occurrence of SCI was associated with higher 90-day mortality (14.7% vs 1.1%; P < .05), longer postoperative hospital stay (22 vs 9 days; P < .05), and severe adverse events, such as acute respiratory insufficiency (44.1% vs 12.7%), acute renal failure (35.3% vs 11.3%), and pneumonia (29.4% vs 4.9%; all P < .05). In adjusted analyses, SCI was associated with worse long-term survival after F/BEVAR for TAAA (hazard ratio, 2.54; 95% CI, 1.37-4.73; P < .003). CONCLUSIONS: Female AAA patients and TAAA patients with cardiac arrhythmias are at highest risk for development of SCI after F/BEVAR. The occurrence of this event was strongly associated with higher major complication rates and worse short-term and long-term survival. This emphasizes a need to further illuminate the value of spinal cord protection protocols in F/BEVAR.

Hypogastric Artery Stenting for Chronic Intermittent Spinal Cord Ischemia After Thoracic Endovascular Aortic Repair.

PURPOSE: To report a case of chronic intermittent spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) and its successful treatment using hypogastric artery stenting. CASE REPORT: A 79-year-old patient presented in May 2013 with a thoracic aortic aneurysm (TAA) and a contained rupture. He urgently underwent TEVAR that covered 274 mm of descending thoracic aorta without immediate postoperative signs of acute SCI. At 3-month follow-up, he reported repeating incidents of sudden lower extremity weakness leading to a fall with a humerus fracture. A neurological consultation revealed the tentative diagnosis of intermittent SCI caused by TEVAR and initially recommended a conservative approach. During the following year there was no clinical improvement of the symptoms. Computed tomography angiography showed a high-grade stenosis of the right hypogastric artery, which was stented in November 2014 to improve the collateral network of spinal cord perfusion. Following treatment, the patient had no further neurological symptoms; at 32 months after the reintervention, the imaging follow-up documented a patent stent and continued exclusion of the TAA. CONCLUSION: Intermittent neurological symptoms after TEVAR should be suspected as chronic intermittent SCI. The improvement of collateral networks of the spinal cord by revascularization of the hypogastric artery is a viable treatment option.

Spinal Cord Ischemia Rescue after Hybrid Total Arch Repair with Frozen Elephant Trunk: A Case Report.

Frozen elephant trunk repair is a technique described to simplify total arch repair for Stanford type A aortic dissection. Spinal cord ischemia is a devastating complication after frozen elephant trunk repair. In this report, we describe a case of spinal cord ischemia resulting in paralysis after frozen elephant trunk repair. Our spinal cord ischemia protocol was implemented and rescued patients from paraplegia. We report a dedicated spinal cord ischemia protocol that can rescue patients from paraplegia after hybrid arch repair with frozen elephant trunk.

Abdominal Aortic Transplantation of Bone Marrow Mesenchymal Stem Cells Regulates the Expression of Ciliary Neurotrophic Factor and Inflammatory Cytokines in a Rat Model of Spinal Cord Ischemia-Reperfusion Injury.

BACKGROUND This study aimed to investigate the effects of abdominal aortic transplantation of bone marrow mesenchymal stem cells (BMMSCs) on the expression of inflammatory cytokines in a rat model of spinal cord ischemia-reperfusion injury. MATERIAL AND METHODS Adult female Sprague-Dawley rats (N=160) were divided into five groups: the sham operation group (N-32); the control group (N=32); the BMMSC transplanted group (N=32); the anti-ciliary neurotrophic factor (CNTF)-treated BMMSC transplanted group (N=32); and the CNTF small interfering RNA (siRNA)-treated BMMSC transplanted group (N=32). Motor behavior was assessed using the Basso, Beattie, and Bresnahan (BBB) locomotor scale. Motor evoked potentials (MEPs) and cortical somatosensory evoked potentials (CSEPs) were measured. Immunohistochemistry, quantitative real-time polymerase chain reaction (qRT-PCR), and Western blot analysis evaluated the expression of spinal inflammatory cytokines. RESULTS Following surgery, compared with the control group the findings in the BMMSC transplant groups included significantly increased BBB scores; the latency and the amplitude of MEP and CSEP were reduced and increased, respectively; spinal neuronal necrosis was reduced; the number of normal neurons increased; CNTF mRNA and protein expression levels increased; expression levels of interleukin-6 (IL-6) were reduced and IL-10 levels were significantly increased (P<0.05). The effects of abdominal aortic BMMSC transplantation were at least partially reversed by both anti-CNTF and CNTF siRNA treatment. CONCLUSIONS In a rat model of spinal cord ischemia-reperfusion injury, abdominal aortic transplantation of BMMSCs increased the expression of CNTF, which improved hindlimb locomotor recovery by regulating the expression of IL-6 and IL-10 to reduce inflammation of the spinal cord.

Spinal Cord Ischemia after Endovascular Aortic Repair of a Unilateral Iliac Artery Dissecting Aneurysm: A Case Report.

PURPOSE: Spinal cord ischemia (SCI) is a rare complication of endovascular repair of abdominal aortic aneurysm that is attributed to the variable anatomy of the artery of Adamkiewicz, embolization of the collateral circulation, or hypoperfusion of cord structures secondary to hypotension. CASE REPORT: A hypertensive 83-year-old male with chronic obstructive pulmonary disease presented with a 2.3-cm right iliac artery dissecting aneurysm. Paraplegia occurred on the first day after endovascular repair of iliac artery aneurysm. Postoperative magnetic resonance imaging showed multiple foci of spinal cord ischemia involvement from T10 to L1. Neither arterial pressure augmentation nor steroid therapy was effective. We hypothesized that the compromised blood flow from the artery of Adamkiewicz, combined with the transient hypotension and embolism, resulted in spinal cord infarction. The patient was eventually transferred to a nursing facility, with no improvement in his neurological status. CONCLUSIONS: SCI after endovascular aortic repair is an extremely rare and unpredictable complication. Physicians should pay more attention to the patients with comorbidities of atherosclerosis, chronic obstructive pulmonary disease, or peripheral artery occlusive disease.

Spinal Cord Infarction due to Fibrocartilaginous Embolism: A Report of 3 Cases.

Fibrocartilaginous embolism (FCE) is an uncommon cause of spinal cord infarction often misdiagnosed as transverse myelitis. The mechanism of ischemia is suspected to be due to retrograde embolization of nucleus pulposus material originating from Schmorl's nodes to the spinal vessels following acute disk herniation. We describe the clinical and imaging findings of FCE in 3 healthy young women with history of trivial spinal cord trauma, and recommend that FCE should be considered in the differential diagnosis of acute myelopathy.

Spinal Cord Ischemia following Elective Endovascular Repair of Infrarenal Aortic Aneurysms: A Systematic Review.

BACKGROUND: Spinal cord ischemia (SCI) after abdominal aortic aneurysm (AAA) endovascular abdominal aortic aneurysm repair (EVAR) is a rare but devastating complication. The mechanism underlying the occurrence of SCI after EVAR seems to be multifactorial and is underreported and not fully elucidated. The aim of the study was to investigate the clinical outcomes in patients with this serious complication. METHODS: A systematic review of the current literature, as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines, was performed to evaluate the incidence of SCI after elective EVAR. PubMed and Scopus databases were systematically searched. Studies reporting on thoracic endovascular aneurysm repair, open repair of AAAs, and symptomatic or ruptured AAAs were excluded. RESULTS: In total, 18 articles reporting 25 cases were included. The mean age was 74.6 ± 7.6 (range: 60-90) years. The mean diameter of AAAs was 5.96 ± 1.0 cm (range: 4.7-8.3). Six cases also had aneurysms in the common iliac arteries. Seventy-one percent of AAAs had characteristics that made EVAR difficult and technically demanding. The mean operative time was prolonged, 254 ± 104.6 min, and associated with extensive intravascular handling. In 41.6% of cases, additional procedures were performed because of the difficult anatomy. Thirty-two percent of the cases had 1 internal iliac artery (IIA) embolized with coils or covered with the stent graft, and 14% had both IIAs compromised. In most of the cases, SCI symptoms presented immediately after the operation, and in 14.8% of patients, the symptoms had late presentation. Almost all cases had motor loss in the form of paraparesis or paraplegia, 54% of the cases also had diminished sensation, and 29.1% of the cases had urinary and/or fecal incontinence. Heterogeneity was observed regarding the management of the disease; in 6 of the cases, cerebrospinal fluid (CSF) drainage was performed, steroids were administered in 5, and in the other cases, an expectant strategy was selected. In 50% of the cases, only small improvement was seen at follow-up. In 25% of the cases, no improvement was seen, and 25% had almost complete recovery. CONCLUSIONS: Our study identified a common pattern among patients who present SCI after EVAR: difficult anatomy, prolonged operative time, additional procedures, and extensive intravascular handling that may have led to embolization. Patency of pelvic circulation preoperatively is also of importance. Regarding outcomes, only 25% of patients recovered, and in certain cases, CSF drainage may have significantly improved chances for recovery.

Immunohistochemical Analysis of the Spinal Cord Ischemia- Effect of Remote Ischemic Preconditioning in a Porcine Model.

BACKGROUND: In experimental settings, remote ischemic preconditioning (RIPC) has shown a positive effect regarding spinal cord protection after local ischemia. In this study, we conducted spinal cord immunohistochemistry to demonstrate the protective effect of RIPC after 24 hours of the regional ischemia. Methods: Twenty piglets were randomized into an RIPC group (n = 10) and a control group (n = 10). The RIPC group underwent transient left hind limb ischemia before systematic left subclavian artery and segmental artery occlusion at the level of the diaphragm. Twenty-four hours later, the thoracic and lumbar spinal cords were harvested, and the oxidative stress markers were immunohistochemically analysed. Results: A total of 18 animals survived the 4-hour follow up (10 in the RIPC group, 8 in the control group) and 14 animals survived the 24-hour follow up (7 in each group). In the single sections of the spinal cord, the antioxidant pathway activation was seen in the RIPC group, as OGG1 and DJ-1/PARK7 activation was higher (P = .038 and P = .047, respectively). Conclusions: The results indicate that the neuroprotective effect of RIPC on the spinal cord after local ischemic insult remains controversial.

Spinal Cord Infarction Presenting as a Hemicord Syndrome: Report of 2 Cases.

Infarction of the spinal cord is a rare entity in clinical practice. Limited literature exists on spinal cord stroke treatment, and the management is often symptomatic. The anterior spinal cord syndrome is the most common phenomenology, but here we present 2 nontraumatic spinal hemicord infarctions in elderly patients and discuss the clinical and radiological characteristics.

Spinal Cord Infarction: Clinical and Radiological Features.

INTRODUCTION: Spinal cord infarction is an uncommon disease varying in its clinical presentation. This study describes the clinical and radiological presentation of spinal cord infarcts in 17 consecutive patients. MATERIAL AND METHODS: Clinical and MR imaging data of 17 patients were reviewed. Inclusion criteria were acute or subacute presentation (peak within 72 hours) and MRI showing typical signal changes on T2WI compatible with spinal cord infarct. Exclusion criteria were clinical or MRI findings suggesting other etiologies. RESULTS: Clinical presentation included dissociative anesthesia, weakness of limbs, back or neck pain, and autonomic symptoms with symptom onset to peak time ranging from few minutes to 48 hours in patients with anterior spinal artery infarct (n = 16), and weakness and sensory loss in ipsilateral upper limb in patient with posterior spinal artery infarct (n = 1). One patient presented with "man-in-the-barrel syndrome (MIB)." MRI findings in anterior spinal artery infarcts included pencillike hyperintensities on T2 sagittal (n = 16, 100%) and "owl eye" appearance on T2 axial (n = 6, 37.5%) images. Diffusion restriction was noted in 8 cases and enhancement was noted in 2 cases. The posterior spinal artery infarct showed T2 hyperintensity in left posterior paramedian triangular distribution in cervical cord (C2-C7). Follow-up was available for 9 patients (period ranging from 15-41 months). Four patients had a favorable outcome who could walk independently, 1 patient could walk with support, and 2 patients were wheelchair bound. Two patients died. CONCLUSION: Spinal cord infarction is a rare but important cause of acute spinal syndrome. Typical distribution and appropriate imaging can help in timely diagnosis.

Spinal cord injury after thoracic endovascular aortic aneurysm repair.

PURPOSE: Thoracic endovascular aortic aneurysm repair (TEVAR) has become a mainstay of therapy for aneurysms and other disorders of the thoracic aorta. The purpose of this narrative review article is to summarize the current literature on the risk factors for and pathophysiology of spinal cord injury (SCI) following TEVAR, and to discuss various intraoperative monitoring and treatment strategies. SOURCE: The articles considered in this review were identified through PubMed using the following search terms: thoracic aortic aneurysm, TEVAR, paralysis+TEVAR, risk factors+TEVAR, spinal cord ischemia+TEVAR, neuromonitoring+thoracic aortic aneurysm, spinal drain, cerebrospinal fluid drainage, treatment of spinal cord ischemia. PRINCIPAL FINDINGS: Spinal cord injury continues to be a challenging complication after TEVAR. Its incidence after TEVAR is not significantly reduced when compared with open thoracoabdominal aortic aneurysm repair. Nevertheless, compared with open procedures, delayed paralysis/paresis is the predominant presentation of SCI after TEVAR. The pathophysiology of SCI is complex and not fully understood, though the evolving concept of the importance of the spinal cord's collateral blood supply network and its imbalance after TEVAR is emerging as a leading factor in the development of SCI. Cerebrospinal fluid drainage, optimal blood pressure management, and newer surgical techniques are important components of the most up-to-date strategies for spinal cord protection. CONCLUSION: Further experimental and clinical research is needed to aid in the discovery of novel neuroprotective strategies for the protection and treatment of SCI following TEVAR.

Lumbar Cerebrospinal Fluid Drainage in Endovascular Aortic Repair - Reference Centre Experience.

INTRODUCTION: Spinal cord ischemia (SCI) and the resulting paraplegia are one of the most feared postoperative complications after thoraco-abdominal aortic surgery, with an incidence 4,3-8,0% after thoracic endovascular aortic repair (TEVAR), increasing patients morbi-mortality. Lumbar cerebrospinal fluid (CSF) drainage catheter is recommended as preventive measure in high risk patients. OBJECTIVE: To evaluate the efficiency and safety of CSF drainage catheter as preventive or therapeutic measure in endovascular aortic repair (EAR). METHODS: Retrospective study in 19 patients submitted to TEVAR or fEVAR (fenestrated endovascular aneurism repair), in whom CSF drainage catheter was used, between January 2010 and March 2017. Collected data regarding demographic, perioperative patients characteristics, neurologic symptoms (NS) and other complications. All patients were submitted to general anesthesia (GA) as result of complexity and length of surgery. Known risk factors (RF) for SCI were taken into account. RESULTS: 19 patients, 89,5% (n=17) male, mean age of 66±9 years. 63,2% were classified as ASA III and 36,8% as ASA IV. 9 patients submitted to TEVAR (47,4%); the remaining were submitted to fEVAR. 73,7 % were programed procedures. There were intraoperative complications in 3 patients: iliac artery (IA) rupture in 2 patients, laceration of the axillary artery in 1 patient, all required surgical repair. All catheters were placed in awake patients, before GA induction, and were left in place 2,5 days. 7 patients needed drainage because of CSF pressure>10mmHg intra- or postoperatively. 3 patients developed early symptoms of SCI (decreased mobility and strength of legs). Complete recovery occurred in all patients, except one who recovered just partially. 1 patient developed late NS: paraparesia on 40th postoperative day (POD) as result of spinal stroke. 30 days mortality was 10,5% (n=2), due to cardiorespiratory arrest- 1 by hypovolemic shock (on 3rd POD), 1 by unknown cause (14th POD). CONCLUSION: This study was limited by the small sample size. CSF drainage catheter was an efficient measure in prevention and treatment of SCI in this sample, since there was no case of complications due to SCI. CSF drainage seems to be an effective technique in preventing SCI. Further studies are required to determine the effectiveness and compare the different methods available for the prevention of SCI complications.

Spinal Cord Infarction in Clinical Neurology: A Review of Characteristics and Long-Term Prognosis in Comparison to Cerebral Infarction.

Spinal cord stroke is rare accounting for 0.3-1% of all strokes and is classified into upper (cervical) and lower (thoracolumbar) strokes. Patients present with severe deficits but later often show good functional improvement. On admission, younger age, male gender, hypertension, diabetes mellitus and elevated blood glucose indicate more severe spinal cord strokes. Treatment of these risk factors is essential in the acute phase. Biphasic spinal cord strokes are seen in one-fifth of the patients. These present with acute or transient sensory spinal cord deficits often preceded by radiating pain between the shoulders, and should be considered and treated as imminent spinal cord strokes. Spinal cord infarction patients are younger and more often women compared to cerebral infarction patients. Traditional cerebrovascular risk factors are less relevant in spinal cord infarction. Spinal cord infarction patients are more likely to be discharged home and show better improvement after initial treatment compared to cerebral infarction patients. On long-term follow-up, spinal cord infarction patients have lower mortality and higher emotional well-being scores than cerebral infarction patients. Despite more chronic pain, the frequency of re-employment is higher among spinal cord infarction patients compared to cerebral infarction patients who are more often afflicted with cognitive function deficits.

Reversible spinal cord ischemia as a complication of acute aortic intramural hematoma.

Aortic intramural hematoma is a variant of acute aortic dissection characterized by localized hemorrhage into the aortic media causing a separation of the intimal and adventitial layers of the aorta. Malperfusion represents an unusual presenting sign of acute intramural hematoma. Herein, we describe the case of a patient with an acute Type A IMH who developed reversible ischemic spinal cord syndrome after presenting with paraplegia as a consequence of malperfusion. A decision was made to delay operative repair and, instead, emergently apply medical interventions to increase spinal cord perfusion pressure. Medical treatment was effective for the treatment of spinal cord ischemia and operative repair of the intramural hematoma was accomplished after complete recovery of neurologic function. This is the third case ever reported of an intramural hematoma presenting in the form of spinal cord ischemia.