Anterior Spinal Artery Syndrome: Rare Precedented Reason of Postoperative Plegia After Spinal Deformity Surgery: Report of 2 Cases.

BACKGROUND: Complications in spinal deformity surgery vary from insignificant to severe. Apart from direct mechanical insult, ischemia can also cause spinal cord injury. Ischemic injury may be detected during surgery or may manifest itself postoperatively. We present 2 cases of anterior spinal artery syndrome. CASE DESCRIPTION: In the first case, a 12-year-old girl developed anterior spinal artery syndrome resulting in total quadriplegia 8 hours after spinal deformity surgery. She was treated with a steroid, immunoglobulin, and low-molecular-weight heparin. She showed complete recovery at 1 year postoperatively both clinically and radiographically. In the second case, a 62-year-old woman experienced sudden loss of motor evoked potentials intraoperatively during dural tear repair after sagittal and coronal alignment was established. The paraplegic patient was diagnosed with anterior spinal artery syndrome at the thoracic level postoperatively. She was treated with a steroid and heparin. At 1 year postoperatively, she has gained much of her strength and has myelomalacia in her spinal cord. CONCLUSIONS: Anterior spinal artery syndrome is a serious condition with a generally poor prognosis. Though treatment should be directed at the underlying cause, the best strategy is to prevent it from occurring. Peroperative blood pressure control, intraoperative neuromonitoring, avoidance from mechanical stress during surgery, and close neurologic and hemodynamic monitorization postoperatively should be performed.

Anterior spinal artery syndrome caused by thoracic disc herniation.

We present a case of a midline thoracic disc herniation causing acute anterior spinal artery (ASA) syndrome successfully managed surgically. A 54-year-old female with no significant past medical history presented with sudden onset severe back pain followed by rapidly evolving paraparesis with urinary and bowel incontinence. Her neurological exam was consistent with ASA syndrome. An MRI revealed T2 signal change in the thoracic spinal cord and midline disc herniation at the level of T8/T9. Spinal angiography revealed an ASA arising the right T11 segmental artery with no flow towards the T8/T9 region. The patient underwent a T8/T9 discectomy with a lateral interbody fusion that resulted in dramatic clinical improvement. A postoperative angiogram confirmed improvement of flow in the ASA. This is the first report of an angiographically confirmed symptomatic ASA syndrome caused by a thoracic disc herniation successfully managed with up-front surgery.

Lund University Cardiac Assist System Induced Liver Laceration and Anterior Cord Infarction After Cardiac Arrest: A Case Report.

We describe a hepatic laceration and subsequent anterior spinal artery syndrome in a 21-year-old man, secondary to prolonged cardiopulmonary resuscitation with a Lund University Cardiac Assist System (LUCAS2) mechanical cardiac compression device. We briefly review the current literature pertaining to hepatic injury from trauma due to cardiopulmonary resuscitation. The etiology of the anterior spinal artery syndrome in this patient is discussed. This case highlights that intra-abdominal causes of hypotension should be considered in patients after a prolonged resuscitation attempt. Extending focused cardiac ultrasound to exclude intra-abdominal free fluid should be routinely considered in these patients.

Anterior Spinal Artery Syndrome in a Patient with Cervical Spondylosis Demonstrated by CT Angiography.

A few published reports have described anterior spinal artery syndrome (ASAS) with cervical spondylosis based on clinical presentation and/or MRI study, but no photographs of anterior spinal arteries were provided in these studies. Here we present a case of ASAS with cervical spondylosis in a CT angiography (CTA) study. A previously healthy 31-year-old man was diagnosed with acute ASAS with cervical spondylosis. Neurological examination revealed four-limb weakness predominant in the distal part of the upper limbs and superficial sensory impairment below the cervical region. T2-weighted images on MRI showed an area of hyperintensity in the gray matter of the cervical cord from C3 to C5 with a disc herniation at the C4,5 vertebral level. CTA demonstrated that ASA was occluded at level C4,5 , which coincided with the location of disc herniation. Anterior spinal cord decompression and fusions were performed. The patient tolerated the procedure well and had complete resolution of his exertionally dependent myelopathic symptoms 1 week later. In conclusion, although ASAS with cervical spondylosis is rare, it can be diagnosed based on clinical symptoms and MRI and identified by CTA of ASA. A good neurological prognosis is anticipated after anterior spinal cord decompression and fusion is performed if disc herniation is responsible for ASA occlusion.

Anterior spinal artery syndrome and aortic dissection.

BACKGROUND: Anterior spinal artery syndrome, usually resulting in flaccid paraplegia, is a rare but disastrous complication that can occur after surgery of aortic aneurysms and aortic dissections. Spinal cord infarct as the initial clinical presentation of aortic dissection is a very rare finding. CASE REPORT: A 42-year-old male patient who comes to the emergency department due to severe chest pain associated with presyncope and paraplegia of the lower limbs in the context of type A aortic dissection. CONCLUSIONS: Recognizing this atypical clinical presentation of aortic dissection and knowing how to approach it is critical for an early diagnosis and to minimize the risk of spinal cord ischemia during surgery.

ANTECEDENTES: La lesión de la médula espinal, generalmente resultante en paraplejia flácida, es una complicación rara, pero desastrosa, que puede ocurrir tras intervenciones quirúrgicas de aneurismas o disecciones de aorta. La presentación clínica inicial de una disección de aorta como un síndrome de la arteria espinal anterior es un hallazgo muy infrecuente. CASO CLÍNICO: Varón de 42 años que acude al servicio de urgencias hospitalario por dolor torácico intenso asociado a cuadro presincopal y paraplejia de miembros inferiores en el contexto de una disección de aorta tipo A. CONCLUSIONES: Reconocer esta forma de presentación clínica y saber cómo realizar un abordaje adecuado es fundamental para el diagnóstico precoz y para minimizar el riesgo quirúrgico de presentar isquemia medular.

Anterior spinal artery syndrome from type A aortic dissection in a patient with Marfan syndrome due to a novel fibrillin mutation.

Type A aortic dissection is a rare but important cardiac surgical emergency. Few reports exist in the literature describing anterior spinal artery syndrome as a presenting feature. We report a case of anterior spinal artery syndrome due to aortic dissection in a patient with Marfan syndrome caused by a novel fibrillin mutation. A 53-year old female presented with chest pain and sudden-onset paralysis. Neurological examination revealed normal upper limb examination, reduced lower limb power and reflexes but normal sensation. CT scanning revealed type A acute aortic dissection which was treated with emergent cardiac surgical repair. At clinic follow up 3 years later, signs of Marfan syndrome were opportunistically noted and genetic testing revealed a novel mutation in the Fibrillin 1 gene. This case emphasises the importance of a good initial clinical assessment, including thorough neurological examination, as well as a low threshold of clinical suspicion for an aortic dissection in such a constellation of symptoms. The importance of family history should also be emphasised given the coincidental diagnosis of Marfan syndrome in a first-degree relative. Furthermore, this case illustrates the classical signs of anterior spinal artery syndrome.

A case of anterior spinal cord syndrome in a patient with unruptured thoracic aortic aneurysm with a mural thrombus.

BACKGROUND: Spinal cord infarction is an uncommon condition. Anterior cord syndrome present with paraparesis or quadriparesis with sparing of vibration and proprioceptive senses. The common causes of anterior cord syndrome are aortic dissection and aortic surgical interventions. Spontaneous unruptured nondissected aortic aneurysms with intramural thrombus can rarely cause anterior cord infarctions. CASE PRESENTATION: We report a case of anterior spinal cord syndrome due to aneurysm of the thoracic aorta with a mural thrombus. A 64 year old male presented with sudden onset paraparesis with a sensory level at T1 with preserved sense of proprioception and vibration. The MRI panspine revealed increased T2 intensity in the anterior portion of the spinal cord from C5 to T10 level with characteristic 'owl eye' appearance on axial imaging. The CT aortogram detected aneurysmal dilatation of the ascending aortic, arch and descending thoracic aorta with significant intimal irregularities, calcified atherosclerotic plaques and a small mural thrombus. CONCLUSION: The possible mechanisms postulated are occlusion of ostia of radicular arteries by the atherosclerotic plaques and mural thrombus or thromboembolism to the anterior spinal artery. Nondissected atherosclerotic aortic aneurysms should be considered in patients presenting with spinal cord infarctions especially in the presence of vascular risk factors and smoking.

Anterior Spinal Artery Syndrome Following Coronary Artery Bypass Grafting: a Case Report.

We present a patient with unstable angina candidate for coronary artery bypass grafting. Saphenous vein graft was used in obtuse marginal and left internal mammary artery to left anterior descending artery properly. After surgery, the patient experienced flaccid paralysis of lower limb and impaired sensation of touch and warmth of knee and below. A computed tomography angiogram of lower limbs and thoracolumbar magnetic resonance imaging showed no abnormality. Based on the symptom, clinical diagnosis of anterior spinal artery syndrome was considered. The artery of Adamkiewicz is an important supplier to the anterior spinal artery. Internal thoracic mammary artery, used in coronary artery bypass grafting, is suspected as a collateral supplier of the artery of Adamkiewicz and has been accused for cause of spinal infarction.

Anterior spinal artery syndrome following coronary artery bypass grafting: a case report

Abstract We present a patient with unstable angina candidate for coronary artery bypass grafting. Saphenous vein graft was used in obtuse marginal and left internal mammary artery to left anterior descending artery properly. After surgery, the patient experienced flaccid paralysis of lower limb and impaired sensation of touch and warmth of knee and below. A computed tomography angiogram of lower limbs and thoracolumbar magnetic resonance imaging showed no abnormality. Based on the symptom, clinical diagnosis of anterior spinal artery syndrome was considered. The artery of Adamkiewicz is an important supplier to the anterior spinal artery. Internal thoracic mammary artery, used in coronary artery bypass grafting, is suspected as a collateral supplier of the artery of Adamkiewicz and has been accused for cause of spinal infarction.

Spinal cord infarction post cardiac arrest in STEMI: A potential complication of intra-aortic balloon pump use.

Intra-aortic balloon pump (IABP) is commonly used as a cardiac assist device in various clinical situations: cardiogenic shock, mechanical complications of acute myocardial infarction, high risk percutaneous coronary interventions, coronary artery bypass graft surgery and refractory unstable angina and ventricular arrhythmias as bridge to therapy. Although current data support its safety, there is limited or no support for its efficacy. We present the case of spinal cord infarction after IABP use in a patient who presented with ST elevation myocardial infarction and cardiac arrest and we discuss the potential mechanism of such a devastating complication.

[The Compression Syndrome of Lumbar Arteries - Case Report of a Rare Disease Pattern]. / Das Kompressionssyndrom der Lumbalarterien - Kasuistik eines seltenen Krankheitsbilds.

STUDY DESIGN: We present a monocentric analysis of the lumbar artery compression syndrome (LACS) in the form of a case report. OBJECTIVES: Literature information was collected about the symptoms, diagnosis and treatment of this rare disorder in the context of the existing data. METHODS: The current medical literature includes only one report about three cases of LACS, collected over 20 years in France and Germany. We compared these cases with the experience of the European Vascular Center Aachen-Maastricht. RESULTS: The symptoms of this rare disorder are dominated by reversible, motion-dependent paralysis of the legs. Compression of the right lumbar arteries by muscular fibres or connective tissue is a fundamental cause. CONCLUSION: Surgical treatment, which means decompression of the lumbar arteries via a thoracolaparotomy, is an appropriate therapy with few complications and good long-term results.

Mechanisms and prevention of anterior spinal artery syndrome following abdominal aortic surgery.

Paraplegia or paraparesis occurring as a complication of thoracic or thoracoabdominal aortic aneurysm repair is a well known phenomenon, but the vast majority of elective abdominal aortic aneurysm repairs are performed without serious neurological complications. Nevertheless, there have been many reported cases of spinal cord ischaemia following the elective repair of abdominal aortic aneurysms (AAA); giving rise to paraplegia, sphincter incontinence and, often, dissociated sensory loss. According to the classification made by Gloviczki et al. (1991), this presentation is classified as type II spinal cord ischaemia, more commonly referred to as anterior spinal artery syndrome (ASAS). It is the most common neurological complication occurring following abdominal aortic surgery with an incidence of 0.1-0.2%. Several aetiological factors, including intra-operative hypotension, embolisation and prolonged aortic crossclamping, have been suggested to cause anterior spinal artery syndrome, but the principal cause has almost always been identified as an alteration in the blood supply to the spinal cord. A review of the literature on the anatomy of the vascular supply of the spinal cord highlights the significance of the anterior spinal artery as well as placing additional emphasis on the great radicular artery of Adamkiewicz (arteria radicularis magna) and the pelvic collateral circulation. Although there have been reported cases of spontaneous recovery, complete recovery is uncommon and awareness and prevention remains the mainstay of treatment. However, being so tragically unpredictable and random, spinal cord ischaemia after abdominal aortic operations appears to be an unpreventable event.

[Cervical medullar infarction in multileveled discopathy]. / Infarctus médullaire cervical dans un contexte de discopathie pluri-étagée.

Spinal cord infarction is a rare but devastating pathology causing acute neurological deficits. The incidence has been estimated to 1% of all strokes. In that case report, our patient has presented anterior spinal artery infarction in C5-C6. The only risk factor founded was a multileveled discopathy wich is known to be an uncommon cause of anterior spinal artery syndrome.

Thoracic disc herniation leads to anterior spinal artery syndrome demonstrated by diffusion-weighted magnetic resonance imaging (DWI): a case report and literature review.

BACKGROUND: Thoracic disc herniation rarely causes acute ischemic events involving the spinal cord. Few reports have suggested this as a mechanism leading to anterior spinal artery syndrome, and none with illustration through diffusion-weighted magnetic resonance imaging (DWI). PURPOSE: The purpose of this study was to report a case of anterior spinal artery syndrome secondary to thoracic disc herniation and demonstrate the first use of DWI to aid in diagnosis of this rare myelopathy. STUDY DESIGN: Case report. METHODS: A 36-year-old woman developed sudden onset of back pain followed by evolving paraparesis and sensory loss consistent with anterior spinal artery distribution ischemia. T2-weighted magnetic resonance imaging (MRI) demonstrated an acute herniated nucleus pulposus at the T7-T8 disc, which produced a focal indentation of the adjacent anterior spinal cord without cord displacement or canal stenosis. T2-weighted hyperintensities were seen at T4-T7 levels with corresponding brightness on DWI and reduction of the apparent diffusion coefficient, consistent with cord ischemia. RESULTS: Remarkably, within just a few days and following conservative treatment, including heparin and steroids, this patient's neurologic status began to show improvement. Within 3 weeks, she was ambulating with assisted devices, and at the 10-month follow-up, the patient had nearly complete neurological improvement. A follow-up MRI at 10 months showed normal T2-weighted imaging except for a 1×2-mm area of anterior-left lateral cord myelomalacia at T4-T5. CONCLUSIONS: Acute thoracic disc herniation with cord contact but without canal stenosis is able to disrupt blood flow to the cord leading to anterior spinal artery distribution ischemia. This case represents the first demonstrated use of DWI in diagnosing this rare cause of anterior spinal artery ischemia.

Anterior spinal artery syndrome in a patient with vasospasm secondary to a ruptured cervical dural arteriovenous fistula.

BACKGROUND: Spinal dural arteriovenous fistulas (DAVF) in the cervical spine are known to cause subarachnoid hemorrhage. Vasospasm after rupture of a DAVF, however, has not previously been reported. CASE PRESENTATION: A 48-year-old woman who presented with the sudden onset of altered mental status. Imaging demonstrated extensive subarachnoid hemorrhage and spinal DAVF at C1 to C2. The patient underwent a suboccipital craniotomy for DAVF ligation. On post-operative day three, she began having acute weakness in all her extremities with proprioception and vibration preserved, whereas pain and temperature sensation was lost. An angiogram demonstrated bilateral vertebral artery vasospasm with no filling of the anterior spinal artery. Bilateral angioplasty of the vertebral arteries was performed successfully and post-angioplasty, the right vertebral artery was filling the anterior spinal artery. The patient clinically improved. She subsequently required treatment with n-butyl cyanoacrylic acid (nBCA) embolization and gamma knife radiosurgery to achieve obliteration of the lesion. CONCLUSIONS: For patients with subarachnoid hemorrhage of unknown origin, differential diagnosis should include DAVF. This patient also presented with vasospasm in the context of ruptured DAVF, a complication previously unreported in the literature. This finding suggests that close monitoring for vasospasm after rupture of DAVF is warranted.