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1.
BMC Neurol ; 19(1): 328, 2019 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-31847829

RESUMO

BACKGROUND: Spontaneous conus medullaris infarction is a rare disease. We describe two patients with spontaneous conus medullaris infarction presenting as acute cauda equina syndrome and their unique electromyography (EMG) findings. CASE PRESENTATION: Two patients developed acute low back pain with mild asymmetric paraparesis, loss of perianal sensation and sphincter dysfunction. Ankle deep tendon reflexes were reduced in bilaterally. Neither patient had cardiovascular risk factors. Magnetic Resonance imaging showed infarction in the conus medullaris. Functional recovery was good in both patients, but progressive asymmetric calf wasting and sphincter dysfunction remained. EMG studies at follow-up of at least 3 years demonstrate active denervation at the muscles innervated by the first sacrum anterior horn cells. CONCLUSION: Spontaneous conus medullaris infarction can occur in healthy individuals and presents as cauda equina syndrome. Findings of needle EMG studies indicate a progressive course of sacrum anterior horn cell disorder during long-term follow-up.


Assuntos
Síndrome da Cauda Equina/etiologia , Infarto , Isquemia do Cordão Espinal , Adulto , Feminino , Humanos , Infarto/complicações , Infarto/diagnóstico por imagem , Infarto/fisiopatologia , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Condução Nervosa , Neuroimagem , Isquemia do Cordão Espinal/complicações , Isquemia do Cordão Espinal/diagnóstico por imagem , Isquemia do Cordão Espinal/fisiopatologia
2.
Vasc Health Risk Manag ; 15: 81-87, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31114214

RESUMO

A 74-year-old patient presented with isolated fecal incontinence 6 weeks following endovascular aneurysm repair. The delayed presentation of spinal cord ischemia was precipitated by commencement of alpha-blockers for benign prostatic hyperplasia. This case stresses that vulnerability to spinal cord perfusion is not limited to the perioperative period. In addition, systemic arterial pressure should be closely monitored in cases of marginal vascular insufficiency of the spinal cord.


Assuntos
Antagonistas de Receptores Adrenérgicos alfa 1/efeitos adversos , Aneurisma da Aorta Abdominal/cirurgia , Pressão Arterial/efeitos dos fármacos , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Hiperplasia Prostática/diagnóstico por imagem , Quinazolinas/efeitos adversos , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/terapia , Idoso , Angiografia Digital , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aortografia/métodos , Angiografia por Tomografia Computadorizada , Incontinência Fecal/etiologia , Incontinência Fecal/terapia , Humanos , Imagem por Ressonância Magnética , Masculino , Hiperplasia Prostática/diagnóstico , Isquemia do Cordão Espinal/diagnóstico por imagem , Isquemia do Cordão Espinal/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
3.
J Stroke Cerebrovasc Dis ; 28(6): e66-e67, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30930242

RESUMO

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.


Assuntos
Doenças das Cartilagens/complicações , Embolia/complicações , Infarto/etiologia , Extremidade Inferior/inervação , Isquemia do Cordão Espinal/etiologia , Medula Espinal/irrigação sanguínea , Extremidade Superior/inervação , Adolescente , Doenças das Cartilagens/diagnóstico por imagem , Doenças das Cartilagens/terapia , Diagnóstico Diferencial , Imagem de Difusão por Ressonância Magnética , Embolia/diagnóstico por imagem , Embolia/terapia , Feminino , Humanos , Infarto/diagnóstico por imagem , Infarto/fisiopatologia , Infarto/terapia , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Isquemia do Cordão Espinal/diagnóstico por imagem , Isquemia do Cordão Espinal/fisiopatologia , Isquemia do Cordão Espinal/terapia , Resultado do Tratamento , Adulto Jovem
4.
Semin Thorac Cardiovasc Surg ; 31(4): 708-712, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30980929

RESUMO

Surgical management of thoracoabdominal aortic aneurysms is complex. In particular, maintaining adequate spinal cord and reno-visceral protection during the operation can be challenging. We describe here a branch-first technique developed at our institution, endeavoring to minimized renal and visceral organ ischemic time, decrease risk of spinal cord injury, and provide a controlled and uncluttered field in which the surgeon can operate.


Assuntos
Aorta/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Adulto , Idoso , Aorta/diagnóstico por imagem , Aorta/fisiopatologia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Fatores de Risco , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Isquemia do Cordão Espinal/prevenção & controle , Resultado do Tratamento
5.
Semin Thorac Cardiovasc Surg ; 31(4): 713-720, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30825587

RESUMO

This article summarizes the anatomically driven pathophysiology of spinal cord injury, the impact of ischemia reperfusion on the cellular level, current research in developing neuronal ischemic tolerance, and promotion of collateralization. It addresses neuroprotective strategies in modern clinical practice, current pharmacologic interventions, and continued challenges in the management of complex aortic disease. The pathophysiology of spinal cord injury includes disruption and recovery of collateral blood flow and the effects of malperfusion on the spinal cord. The optimal approach to spinal cord protection is to employ an integrated and protocolized set of strategies to simultaneously maximize spinal cord blood flow, improve ischemic tolerance, and promote collateralization. In the laboratory setting, investigation should continue to pursue a more granular understanding of ischemic injury and seek to translate protective therapies to clinical practice.


Assuntos
Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Isquemia do Cordão Espinal/prevenção & controle , Medula Espinal/irrigação sanguínea , Procedimentos Cirúrgicos Vasculares , Aorta Torácica/fisiopatologia , Doenças da Aorta/mortalidade , Doenças da Aorta/fisiopatologia , Circulação Colateral , Humanos , Fluxo Sanguíneo Regional , Medição de Risco , Fatores de Risco , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/mortalidade , Isquemia do Cordão Espinal/fisiopatologia , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos
6.
Ann Vasc Surg ; 58: 384.e9-384.e14, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30769073

RESUMO

Spinal cord ischemia is one of the most unpredictable and feared complications after open surgical or endovascular thoracic aortic repair. Protection of collateral network branches that contribute blood supply to spinal cord is fundamental in the prevention of this catastrophic condition. We report the case of a patient who underwent emergent endovascular treatment for a type B aortic dissection complicated by rupture of the false lumen, with intentional coverage of the left subclavian artery without revascularization. The patient developed paraplegia on the 10th postoperative day, which did not significantly improve with immediate cerebrospinal fluid drainage but fully recovered after urgent left carotid-subclavian bypass.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Paraplegia/cirurgia , Isquemia do Cordão Espinal/cirurgia , Artéria Subclávia/cirurgia , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/fisiopatologia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/fisiopatologia , Aortografia/métodos , Circulação Colateral , Angiografia por Tomografia Computadorizada , Drenagem , Humanos , Masculino , Pessoa de Meia-Idade , Paraplegia/diagnóstico , Paraplegia/etiologia , Paraplegia/fisiopatologia , Recuperação de Função Fisiológica , Fluxo Sanguíneo Regional , Reoperação , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Artéria Subclávia/diagnóstico por imagem , Artéria Subclávia/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
7.
Ann Vasc Surg ; 59: 306.e1-306.e5, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30684624

RESUMO

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.


Assuntos
Aneurisma Dissecante/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Aneurisma Ilíaco/cirurgia , Isquemia do Cordão Espinal/etiologia , Idoso de 80 Anos ou mais , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/fisiopatologia , Aortografia/métodos , Angiografia por Tomografia Computadorizada , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Aneurisma Ilíaco/fisiopatologia , Imagem por Ressonância Magnética , Masculino , Paraplegia/etiologia , Paraplegia/fisiopatologia , Paraplegia/terapia , Fatores de Risco , Isquemia do Cordão Espinal/diagnóstico por imagem , Isquemia do Cordão Espinal/fisiopatologia , Isquemia do Cordão Espinal/terapia , Resultado do Tratamento
8.
Thorac Cardiovasc Surg ; 67(5): 379-384, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29715704

RESUMO

BACKGROUND: To assess risks and benefits of a standardized strategy to prevent symptomatic spinal cord ischemia (SSCI) after thoracic endovascular repair (TEVAR) using routine cerebrospinal fluid (CSF) catheter placement and evoked potential (EP) monitoring. METHODS: One hundred and ninety-five patients underwent 223 SSCI low-risk TEVAR procedures between 1998 and 2014. CSF catheter was used to measure CSF pressure and drain CSF if necessary throughout the procedure and up to 24 hours thereafter. EPs were used to monitor spinal cord integrity throughout the procedure. RESULTS: Underlying pathologies included descending thoracic aortic aneurysm in 115 (52%), type B aortic dissection in 85 (38%), traumatic aortic rupture in 16 (7%), and others in 7 (3%) patients. CSF catheter was inserted before TEVAR in 116 procedures (52%). Active CSF draining was required in 29 patients (25%). The CSF catheter caused no major and 11 (10%) minor complications. EP were monitored during 88 (40%) procedures. We observed a reduction in the amplitude, prolonged latencies, or complete signal loss in nine procedures. There were no EP monitoring-related complications. SSCI incidence was higher in patients without CSF drainage (0.8% vs 4.7%, p = 0.031). CONCLUSION: Use of CSF drainage is associated with a significant lower incidence of SSCI after SSCI low-risk TEVAR than nonuse, whereas the complication rate associated with CSF drainage insertion or removal is very low. Routine EP monitoring is a useful tool to detect immediate arterial inflow obstruction to the spinal cord. The combination of these two methods serves as a safe and reliable standardized strategy in reducing the incidence of SSCI to a minimum.


Assuntos
Aorta Torácica/cirurgia , Implante de Prótese Vascular , Cateterismo , Pressão do Líquido Cefalorraquidiano , Procedimentos Endovasculares , Potencial Evocado Motor , Monitorização Neurofisiológica Intraoperatória/métodos , Isquemia do Cordão Espinal/prevenção & controle , Idoso , Aorta Torácica/fisiopatologia , Implante de Prótese Vascular/efeitos adversos , Cateterismo/efeitos adversos , Cateterismo/instrumentação , Cateteres , Drenagem/instrumentação , Eletroencefalografia , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
9.
J Vasc Surg ; 69(2): 357-366, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30385148

RESUMO

OBJECTIVE: The aim of our study was to analyze the incidence of spinal cord ischemia (SCI) in patients presenting with complex aortic aneurysms treated with endovascular aneurysm repair (EVAR) and to identify risk factors associated with this complication. METHODS: A retrospective study was undertaken of prospectively collected data including patients presenting with complex aortic aneurysm (pararenal abdominal aortic aneurysm and thoracoabdominal aortic aneurysm) treated with fenestrated EVAR (F-EVAR) or branched EVAR (B-EVAR). The primary end point was the incidence of SCI and the assessment of any associated factors. RESULTS: Between January 2011 and August 2017, a total of 243 patients (mean aneurysm diameter, 65.2 ± 15.3 mm; mean age, 72.4 ± 7.5 years; 73% male) were treated with F-EVAR or B-EVAR. Asymptomatic patients were treated in 73% of the cases (177/243, in contrast to 27% urgent), and 52% (126/243) were treated for thoracoabdominal aortic aneurysm (in contrast to 48% for pararenal abdominal aortic aneurysm). F-EVAR (mean number of fenestrations, 3.3/case) and B-EVAR (mean number of branches, 3.7/case) were undertaken in 67% (164/243) and 33% (79/243), respectively. The total incidence of SCI was 17.7% [43/243; paraplegia in 4% (10/243) and paraparesis in 13.7% (33/243)]. Most of the patients with SCI presented with immediate postoperative symptoms (72% [31/43]). A spinal drain was preoperatively placed in 53% (130/243) and was associated with the prevention of SCI (SCI with spinal drainage, 12% [16/130]; SCI without spinal drainage, 24% [27/113]; P = .018). The 30-day mortality rate was 9% (21/243). After multiple logistic regression analysis, SCI was associated with preoperative renal function (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m2: odds ratio [OR], 2.43; 95% confidence interval [CI], 1.18-4.99; P = .016) and the number of vertebral segments covered (SCI with higher position of proximal stent in terms of vertebra: OR, 1.2; 95% CI, 1.1-1.3; P = .000). A similar outcome was derived when the height of the proximal end of the stent graft was replaced by the total length of aortic coverage (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m2: OR, 2.36 [95% CI, 1.11-5.00; P = .025]; SCI with longer length of aortic coverage: OR, 1.01 [95% CI, 1.003-1.009; P = .000]). CONCLUSIONS: The majority of SCI incidence after F-EVAR or B-EVAR of complex aortic aneurysms is manifested immediately postoperatively. The use of preoperative spinal drainage may prevent SCI. Patients with GRF <60 mL/min/1.73 m2 and with longer aortic stent graft coverage are at higher risk of SCI.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Isquemia do Cordão Espinal/epidemiologia , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Abdominal/fisiopatologia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/fisiopatologia , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/mortalidade , Feminino , Taxa de Filtração Glomerular , Humanos , Incidência , Rim/fisiopatologia , Masculino , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Isquemia do Cordão Espinal/diagnóstico por imagem , Isquemia do Cordão Espinal/mortalidade , Isquemia do Cordão Espinal/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
10.
Vasc Endovascular Surg ; 53(3): 230-241, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30572790

RESUMO

INTRODUCTION:: Despite advances in perioperative critical care and surgical technique, spinal cord ischemia remains a devastating complication of thoracic and thoracoabdominal aortic aneurysm repair. Biochemical markers present in peripheral blood and cerebrospinal fluid (CSF) may be useful in assessing spinal cord injury. We systematically analyze and report the role of all reported biochemical markers that have been used in assessing and diagnosing spinal cord ischemia in thoracic and thoracoabdominal aortic aneurysm repair. METHODS:: Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used for this review. Published literature was searched to identify all studies reporting on the use of biochemical markers in thoracoabdominal aortic aneurysm repair in the assessment of spinal cord ischemia. Marker-specific and patient-specific data were extracted from all studies and where possible, subgroup analysis was performed on marker-specific data sets. RESULTS:: Fourteen studies of 321 patients undergoing thoracic and thoracoabdominal aortic aneurysm repair were eligible for further analysis. Seven distinct biochemical markers were used in both CSF and blood samples: S100B proteins (S100B), neurone-specific enolase, lactate dehydrogenase, glial fibrillary acidic protein (GFAp), neurofilament triplet protein (NFL) and Tau protein, and glucose. There was substantial evidence demonstrating the heightened levels of S100, NFL, and GFAp in CSF in patients with spinal cord ischemia. There is however, wide variability in the correlation of the same 6 biochemical markers in peripheral blood and spinal cord ischemia. CONCLUSIONS:: In patients with spinal cord injury, dramatic rises occur with S100B, NFL, and GFAp in CSF. However, further work is needed if biochemical markers are to impact on the future of thoracoabdominal aortic aneurysm repair.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Isquemia do Cordão Espinal/sangue , Isquemia do Cordão Espinal/líquido cefalorraquidiano , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Torácica/sangue , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Biomarcadores/sangue , Biomarcadores/líquido cefalorraquidiano , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Fluxo Sanguíneo Regional , Reprodutibilidade dos Testes , Fatores de Risco , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/fisiopatologia , Resultado do Tratamento , Adulto Jovem
11.
J Vasc Surg ; 69(6): 1655-1663, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30497866

RESUMO

OBJECTIVE: Staged endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs) with temporary perfusion of the sac through a branch left unstented or a dedicated branch is a strategy intended to reduce the risk of postoperative spinal cord ischemia (SCI). However, potential complications of this approach are aneurysm sac progression between stages, visceral embolism, and occlusion or displacement of components. We here present the "bare branch" technique, a safe adjunct to TAAA repair in terms of interstage complications. METHODS: In the first step, one branch, preferentially the one for the celiac trunk, is stented by a bare stent; in the second step, the bare branch is relined with a covered stent. There were 32 TAAAs (5 type I, 6 type II, 16 type III, 5 type IV) treated by this approach at our center from January 2015 to December 2017 (median follow-up, 13 months [range, 2-24 months]). Data were prospectively collected and retrospectively analyzed. Primary end points were aneurysm sac exclusion and freedom from major adverse events, which included SCI. Secondary end points were freedom from aneurysm growth between the stages and freedom from minor adverse events. RESULTS: Preoperative mean maximum diameter was 68.4 mm; 32 endografts (8 off-the-shelf and 24 custom-made devices) were used. The mean aortic coverage was 364 mm. The mean interval time between the two stages was 10.5 weeks (range, 7-20 weeks). In-hospital mortality was 0%. Type I or type III endoleak rate was 3.2%, whereas one type II endoleak was registered (3.2%). Two patients showed paraparesis, one after the first stage and one after the second stage, both noted at 4/5 on the Tarlov scale, and fully recovered so that the SCI rate was 6.4% with 0% permanent neurologic deficit. Interstage mean maximum diameter was 68.6 mm (P > .05). After the second step, there was an average of 4.7 spinal arteries (standard deviation, 1.4; P < .05) per patient with an increase in visibility and of diameter by 0.7 mm (standard deviation, 0.4 mm). CONCLUSIONS: This is a reproducible adjunct to staged TAAA endovascular repair. The use of a bare branch instead of a branch left completely open has the clear advantage of an easy catheterization in the second step. Furthermore, by having the target vessel stented with a bare stent, the risk of embolism is avoided. In this experience, there was no significant aneurysm sac growth in between the steps. Further comparative studies may determine whether there are different hemodynamic forces with this technique with respect to those already described in the literature.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Isquemia do Cordão Espinal/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervalo Livre de Progressão , Desenho de Prótese , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Fatores de Risco , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Stents , Fatores de Tempo
12.
J Neurol Sci ; 395: 84-87, 2018 12 15.
Artigo em Inglês | MEDLINE | ID: mdl-30300819

RESUMO

This paper illustrates the cases of two patients with an acute onset of right brachial neuropathic pain, flaccid paralysis and contralateral thermal and thermal pain hypoesthesia, without posterior column impairment nor pyramidal signs below the segmental lesion. MRI showed right sided spinal cord infarction, in the anterior spinal artery territory between C1 and C5 in one patient and between C3 and C7 in the other. Contact Heat Evoked Potentials and Quantitative Thermal Sensory testing are consistent with contralateral, but not ipsilateral, spinothalamic tract involvement. Electromyographic results established ipsilateral segmental denervation and somatosensory evoked responses were consistent with dorsal column sparing. Unilateral anterior cervical spinal cord infarction may present with acute ipsilateral segmental neuropathic pain, lower motor neurone-type weakness, contralateral thermoanalgesia and no pyramidal signs. The ipsilateral pain provides novel evidence that in some instances, ventral roots can play a role in nociception in humans. The infarcted territory may result from occlusion of a sulcal commissural artery or a number of more proximal vessels (including a single or duplicated anterior spinal artery, vertebral arteries or feeding radicular arteries).


Assuntos
Infarto/complicações , Infarto/fisiopatologia , Neuralgia/complicações , Neuralgia/fisiopatologia , Isquemia do Cordão Espinal/complicações , Isquemia do Cordão Espinal/fisiopatologia , Vias Aferentes/diagnóstico por imagem , Vias Aferentes/fisiopatologia , Medula Cervical/irrigação sanguínea , Medula Cervical/diagnóstico por imagem , Medula Cervical/fisiopatologia , Feminino , Humanos , Infarto/diagnóstico por imagem , Infarto/tratamento farmacológico , Neuralgia/diagnóstico por imagem , Neuralgia/tratamento farmacológico , Células Receptoras Sensoriais/fisiologia , Isquemia do Cordão Espinal/diagnóstico por imagem , Isquemia do Cordão Espinal/tratamento farmacológico , Raízes Nervosas Espinhais/diagnóstico por imagem , Raízes Nervosas Espinhais/fisiopatologia , Falha de Tratamento , Adulto Jovem
13.
Kyobu Geka ; 71(10): 769-773, 2018 09.
Artigo em Japonês | MEDLINE | ID: mdl-30310025

RESUMO

Near infra-red spectroscopy (NIRS) and motor evoked potentials (MEP) have been used to monitor brain and spinal cord ischemia. NIRS calculates oxygen saturation of hemoglobin, based on the modified Beer-Lambert law. It correlates with the change in regional tissue blood flow. However, the technology is not matured enough for the measured value to be used as an index of tissue oxygenation, so that relative change should be carefully followed. Myogenic MEP has widely been used to monitor spinal cord ischemia, since the introduction of pulse train transcranial electrical stimulation. It evaluates motor pathways from the cortex to the muscle. Therefore it is influenced by non-spinal cord factors such as peripheral nerve ischemia. It is highly sensitive and shows changes in the early phase of spinal cord ischemia. On the other hand, its vulnerability to anesthesia requires special anesthetic consideration, and baseline amplitude fluctuation is common. Specificity is thus low, and the results should be interpreted together with the operative findings.


Assuntos
Circulação Cerebrovascular , Potencial Evocado Motor , Espectroscopia de Luz Próxima ao Infravermelho , Isquemia do Cordão Espinal/fisiopatologia , Anestesia/métodos , Potenciais Evocados , Humanos , Monitorização Intraoperatória , Consumo de Oxigênio , Sensibilidade e Especificidade , Estimulação Transcraniana por Corrente Contínua
14.
J Stroke Cerebrovasc Dis ; 27(10): 2810-2821, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30093205

RESUMO

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.


Assuntos
Imagem de Difusão por Ressonância Magnética , Infarto/diagnóstico por imagem , Isquemia do Cordão Espinal/diagnóstico por imagem , Medula Espinal/irrigação sanguínea , Medula Espinal/diagnóstico por imagem , Caminhada , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Deambulação com Auxílio , Avaliação da Deficiência , Feminino , Humanos , Infarto/etiologia , Infarto/fisiopatologia , Infarto/terapia , Masculino , Pessoa de Meia-Idade , Limitação da Mobilidade , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Medula Espinal/fisiopatologia , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Isquemia do Cordão Espinal/terapia , Fatores de Tempo , Resultado do Tratamento , Cadeiras de Rodas , Adulto Jovem
15.
World Neurosurg ; 119: e1029-e1034, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30144617

RESUMO

BACKGROUND: Adamkiewicz arteries vasospasm in spinal cord subarachnoid hemorrhage (SAH) can affect the spinal cord. Although muscle dysfunction of extremities is a common problem after spinal cord ischemia induced by SAH, to our knowledge there are no studies on degenerative changes in peripheral nerves. We studied the histopathologic changes in sciatic nerves after spinal SAH. METHODS: This study was carried out on 19 rabbits. Five of them were used as control animals, 5 were in the sham group, and 9 were in the study group. For the procedure, 0.5 cm3 of serum saline for the sham group and autologous arterial blood for the study group was injected into the lumbar subarachnoid space at the L5 level. After 2 weeks of follow-up, the sciatic nerve roots at the L5-S3 levels with spinal cords and sciatic nerves were bilaterally extracted to the levels of the collum femoris. The specimens were evaluated by stereologic methods, and degenerated sciatic nerve axons were estimated by Cavalieri methods. Kruskal-Wallis and Mann-Whitney U tests were used for data analysis. Differences of P < 0.005 were evaluated as significant. RESULTS: The mean number of degenerated axon density per square millimeter of sciatic nerve at the collum femoris level was 7 ± 2/mm2 in the control group, 23 ± 7/mm2 in the sham group (P < 0.005), and 125 ± 32/mm2 in the SAH group (P < 0.00005). Statistical analysis showed that spinal SAH may cause axonal degeneration in the peripheral nerves. CONCLUSIONS: We concluded that SAHs frequently affect the spinal cord and result in axonal injury to peripheral nerves, of which there is no mention in the literature.


Assuntos
Transtornos Neurológicos da Marcha/fisiopatologia , Debilidade Muscular/fisiopatologia , Degeneração Neural/fisiopatologia , Paralisia/fisiopatologia , Nervo Isquiático/fisiopatologia , Hemorragia Subaracnóidea/fisiopatologia , Animais , Modelos Animais de Doenças , Transtornos Neurológicos da Marcha/etiologia , Transtornos Neurológicos da Marcha/patologia , Debilidade Muscular/etiologia , Debilidade Muscular/patologia , Degeneração Neural/etiologia , Degeneração Neural/patologia , Paralisia/etiologia , Paralisia/patologia , Coelhos , Nervo Isquiático/lesões , Nervo Isquiático/patologia , Medula Espinal/patologia , Medula Espinal/fisiopatologia , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/patologia , Isquemia do Cordão Espinal/fisiopatologia , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/patologia
16.
J Transl Med ; 16(1): 209, 2018 07 21.
Artigo em Inglês | MEDLINE | ID: mdl-30031397

RESUMO

BACKGROUND: Dexmedetomidine (Dex) can improve neuronal viability and protect the spinal cord from ischemia-reperfusion (I/R) injury, but the underlying mechanisms are not fully understood. This study investigated the effects of dexmedetomidine on the toll-like receptor 4 (TLR4)-mediated nuclear factor κB (NF-κB) inflammatory system and caspase-3 dependent apoptosis induced by spinal cord ischemia-reperfusion injury. METHODS: Twenty-four rabbits were divided into three groups: I/R, Dex (10 µg/kg/h prior to ischemia until reperfusion), and Sham. Abdominal aortic occlusion was carried out for 30 min in the I/R and Dex groups. Hindlimb motor function was assessed using the Tarlov scoring system for gait evaluation. Motor neuron survival and apoptosis in the ventral grey matter were assessed by haematoxylin-eosin staining and terminal deoxynucleotidyl transferase-mediated dUTP biotin nick end labelling staining. The expression and localisation of ionised calcium-binding adaptor molecule 1, TLR4, NF-κB and caspase-3 were assessed by immunoreactivity analysis. The levels of interleukin 1ß and tumour necrosis factor α were assessed using enzyme-linked immunosorbent assays. RESULTS: Perioperative treatment with dexmedetomidine was associated with a significant preservation of locomotor function following spinal cord ischemia-reperfusion injury with increased neuronal survival in the spinal cord compared to control. In addition, dexmedetomidine suppressed microglial activation, inhibited the TLR4-mediated NF-κB signalling pathway, and inhibited the caspase-3 dependent apoptosis. CONCLUSIONS: Dexmedetomidine confers neuroprotection against spinal cord ischemia-reperfusion injury through suppression of spinal cord inflammation and neuronal apoptosis. A reduction in microglial activation and inhibition of both the TLR4-mediated NF-κB signalling pathway and caspase-3 dependent apoptosis are implicated.


Assuntos
Apoptose , Dexmedetomidina/uso terapêutico , Inflamação/patologia , Traumatismo por Reperfusão/tratamento farmacológico , Isquemia do Cordão Espinal/tratamento farmacológico , Animais , Apoptose/efeitos dos fármacos , Pressão Sanguínea/efeitos dos fármacos , Caspase 3/metabolismo , Dexmedetomidina/farmacologia , Feminino , Frequência Cardíaca/efeitos dos fármacos , Masculino , Microglia/efeitos dos fármacos , Microglia/metabolismo , Microglia/patologia , Modelos Biológicos , Atividade Motora/efeitos dos fármacos , NF-kappa B/metabolismo , Coelhos , Traumatismo por Reperfusão/complicações , Traumatismo por Reperfusão/patologia , Traumatismo por Reperfusão/fisiopatologia , Transdução de Sinais/efeitos dos fármacos , Isquemia do Cordão Espinal/complicações , Isquemia do Cordão Espinal/patologia , Isquemia do Cordão Espinal/fisiopatologia , Receptor 4 Toll-Like/metabolismo
17.
J Biol Regul Homeost Agents ; 32(4): 803-813, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30043562

RESUMO

Spinal cord ischemia-reperfusion injury (IRI) results in overproduction of reactive oxygen species leading to tissue oxidative stress which impacts the neuronal network in the spinal cord as well as glial cells. We investigated the expression of Nuclear factor erythroid 2-related factor 2 (Nrf2) in neurons and glial cells after occlusion of the abdominal aorta followed by IRI as well as the time-dependent expression of Nrf2 in the same cells. The experimental method of transient aortic occlusion was carried out on rats by cross-clamping of the abdominal aorta for 45 minutes. The animals used for this study were sacrificed 1 h, 6 h, and 48 h after reperfusion to determine time-related changes of Nrf2 expression, as well as changes of astrocyte activity in the spinal cord. Immunofluorescence results showed an increase in the staining intensity of Nrf2 expression in the neurons following ischemia with highest intensity 48 h post-reperfusion and an increase in a number of reactive astrocytes. Western blot analysis showed that Nrf2 protein expression increased in a cytoplasmic and nuclear fraction as early as 1 h after reperfusion and remained active 48 h after, resulting in increased expression of the main Nrf2 target gene HO-1. In conclusion, substances that enhance expression of Nrf2 may have the potential to prevent cellular damage to the spinal cord caused by IRI.


Assuntos
Colina O-Acetiltransferase/biossíntese , Fator 2 Relacionado a NF-E2/biossíntese , Traumatismo por Reperfusão/metabolismo , Isquemia do Cordão Espinal/metabolismo , Animais , Masculino , Neurônios/metabolismo , Neurônios/patologia , Estresse Oxidativo/fisiologia , Ratos , Ratos Wistar , Traumatismo por Reperfusão/fisiopatologia , Isquemia do Cordão Espinal/fisiopatologia
18.
Ann Vasc Surg ; 52: 280-291, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29885430

RESUMO

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.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Isquemia do Cordão Espinal/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Abdominal/fisiopatologia , Implante de Prótese Vascular/mortalidade , Comorbidade , Procedimentos Cirúrgicos Eletivos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fluxo Sanguíneo Regional , Fatores de Risco , Isquemia do Cordão Espinal/mortalidade , Isquemia do Cordão Espinal/fisiopatologia , Isquemia do Cordão Espinal/terapia , Resultado do Tratamento
20.
J Thorac Cardiovasc Surg ; 155(6): 2505-2516, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29523405

RESUMO

BACKGROUND: Paraplegia remains the most feared complication of complex thoracoabdominal aortic intervention. Although erythropoietin (EPO) has demonstrated neuroprotective effects in spinal cord ischemia, it does not work until expression of the beta common receptor subunit of the EPO receptor (ßcR) is induced by ischemia. We hypothesized that the ßcR can be induced by diazoxide (DZ), amplifying the neuroprotective effects of EPO in spinal cord ischemia-reperfusion injury. METHODS: For the DZ time trial, adult male C57/BL6 mice received DZ (20 mg/kg) by oral gavage. Spinal cords were harvested after 0, 12, 24, 36, and 48 hours of administration. To evaluate optimal dosing, DZ was administered at 0, 5, 10, 20, and 40 mg/kg. The expression of ßcR was assessed by Western blot analysis. Five groups were studied: PBS (pretreatment)+PBS (immediately before), PBS+EPO, DZ+PBS, DZ+EPO, and sham (without cross-clamping). Spinal cord ischemia was induced by 4 minutes of thoracic aortic cross-clamping. Functional scoring (Basso Mouse Score) was done at 12-hour intervals for 48 hours, and spinal cords were harvested for histological analysis. RESULTS: Western blot analysis demonstrated that optimal ßcR up-regulation occurred at 36 hours after DZ administration, and the optimal DZ dosage for ßcR induction was 20 mg/kg. Motor function at 48 hours after treatment was significantly better preserved in the DZ+EPO group compared with all other groups, and was significantly better preserved in the DZ only and EPO only groups compared with control (PBS+PBS). CONCLUSIONS: Pharmacologic up-regulation of ßcR with DZ can increase the efficacy of EPO in preventing spinal cord ischemia and reperfusion injury. Improved understanding of this synergetic mechanism may serve to further prevent ischemic complications for high-risk aortic intervention.


Assuntos
Eritropoetina/farmacologia , Fármacos Neuroprotetores/farmacologia , Receptores da Eritropoetina/metabolismo , Traumatismos da Medula Espinal/fisiopatologia , Isquemia do Cordão Espinal/fisiopatologia , Medula Espinal/efeitos dos fármacos , Animais , Diazóxido/farmacologia , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Transdução de Sinais , Medula Espinal/química , Medula Espinal/metabolismo , Medula Espinal/fisiopatologia , Traumatismos da Medula Espinal/metabolismo , Isquemia do Cordão Espinal/metabolismo
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