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1.
Zhonghua Wai Ke Za Zhi ; 58(11): 817-821, 2020 Nov 01.
Artigo em Chinês | MEDLINE | ID: mdl-33120441

RESUMO

It is more than 20 years since the first endovascular repair of thoracoabdominal aortic aneurysm was performed. Significantly reducing risk of morbidity and mortality compared with open aortic repair, the advent of endovascular repair has revolutionized the treatment of complex aortic disease. It is now the first-line treatment for most thoracoabdominal aortic aneurysm patients. However, spinal cord ischemia (SCI) remains one of the most threatening complications after the procedure, and significantly reduces overall survival. The pathophysiology of spinal cord ischemia remains unclear but may well be multifactorial. Risk factors for SCI include excessive aortic coverage, detriment to the collateral network through occlusion of the left subclavian or internal iliac arteries, perioperative hypotension and chronic renal failure. SCI could be predicted, prevented and ameliorated through the application of motor evoked potential, permissive perioperative hypertension, cerebrospinal fluid drainage (CSFD), preoperative or concomitant left subclavian artery (LSA) revascularization and some drugs. However, there are certain complications and contraindications for CSFD and arterial revascularization. As a result, we must balance the pros and cons of these invasive measures. So we summarize our clinical experience and propose the employment of LSA revascularization and CSFD in certain kinds of high-risk patients respectively. With the development of technology and preventive measures, we believe that SCI could be minimized in the forseeable future.


Assuntos
Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Isquemia do Cordão Espinal , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Humanos , Estudos Retrospectivos , Fatores de Risco , Medula Espinal/irrigação sanguínea , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/prevenção & controle , Resultado do Tratamento
2.
Medicine (Baltimore) ; 99(32): e21579, 2020 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-32769906

RESUMO

Posterior vertebral column resection (PVCR) was the most powerful technique for treating severe rigid spinal deformity, but it has been plagued with high neurologic deficits risk. The fluctuations of spinal cord blood flow (SCBF) play an important role in secondary spinal cord injury during deformity correction surgery.The objective of this study was to first provide the characteristic of SCBF during PVCR with spinal column shortening in severe rigid spinal deformity.Severe rigid scoliokyphosis patients received PVCR above L1 level were included in this prospective study. Patients with simple kyphosis, intraspinal pathology and any degree of neurologic deficits were excluded. The deformity correction was based on spinal column shortening over the resected gap during PVCR. Laser Doppler flowmetry was used to monitor the SCBF at different surgical stages.There were 12 severe rigid scoliokyphosis patients in the study. The baseline SCBF was 316 ±â€Š86 perfusion unite (PU), and the SCBF decreased to 228 ±â€Š68 PU after VCR (P = .008). The SCBF increased to 296 ±â€Š102 PU after the middle shortening and correction which has a 121% increased comparison to the SCBF after VCR (P = .02). The SCBF will slightly decrease to 271 ±â€Š65 PU at final fixation. The postoperative neural physical examination of all patients was negative, and the MEP and SSEP of all patients did not reach the alarm value during surgery.These results indicate that PVCR is accompanied by a change in SCBF, a proper spinal cord shortening can protect the SCBF and can prevent a secondary spinal cord injury during the surgery.


Assuntos
Cifose/cirurgia , Procedimentos Neurocirúrgicos/efeitos adversos , Escoliose/cirurgia , Medula Espinal/irrigação sanguínea , Coluna Vertebral/cirurgia , Adolescente , Adulto , Feminino , Humanos , Cifose/complicações , Masculino , Procedimentos Neurocirúrgicos/métodos , Estudos Prospectivos , Escoliose/complicações , Medula Espinal/cirurgia , Coluna Vertebral/fisiopatologia , Resultado do Tratamento
3.
J Trauma Acute Care Surg ; 89(2): 320-328, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32740640

RESUMO

BACKGROUND: Noncompressible hemorrhage remains a high-mortality injury, and aortic balloon occlusion poses limitations in terms of distal ischemic injury. Our hypothesis was that a retrievable Rescue stent would confer improved outcome over aortic balloon occlusion. METHODS: A three-tier, retrievable stent graft was laser welded from nitinol and polytetrafluoroethylene to provide rapid thoracic and abdominal coverage with an interval bare metal segment to preserve visceral flow. Anesthetized swine had injury of the thoracic or abdominal aorta followed by balloon occlusion or a Rescue stent. A 1-hour long damage-control phase with blood repletion was used to simulate the prolonged interval between injury and repair, especially in the battlefield setting. Following the damage-control phase, the balloon or stent were retrieved followed by vascular repair and recovery to 48 hours. Animals were compared in terms of hemodynamics, blood loss, neurophysiologic spinal cord ischemia, ischemic organ injury, and survival. RESULTS: Despite antegrade hemorrhage control, balloon occlusion averaged 3.5 L of retrograde hemorrhage, loss of visceral perfusion, and permanent spinal cord ischemia by neurophysiology in six of seven animals. After permanent repair, all balloon occlusion animals died with only a single short term (5 hours) survivor. Conversely, Rescue stent animals revealed rapid hemorrhage control (in under 2 minutes) whether the injury was thoracic or abdominal with improved hemodynamics, preserved visceral flow, reduced spinal cord ischemia, negligible histologic organ injury and survival to end of study in all abdominal injured animals (n = 6) and four of six thoracic injured animals, with two deaths related to arrhythmia. CONCLUSION: Compared with aortic balloon occlusion, a Rescue stent offers superior hemorrhage control and survival by virtue of reduced ischemic injury and direct control of the hemorrhagic injury. The Rescue stent may become a useful tool for damage control, especially on the battlefield where definitive repair presents logistical challenges.


Assuntos
Aorta/lesões , Aorta/cirurgia , Oclusão com Balão , Procedimentos Endovasculares , Hemorragia/cirurgia , Stents , Animais , Hemodinâmica , Hemorragia/etiologia , Hemorragia/fisiopatologia , Hemorragia/prevenção & controle , Isquemia/etiologia , Isquemia/prevenção & controle , Modelos Animais , Medula Espinal/irrigação sanguínea , Suínos , Resultado do Tratamento , Vísceras/irrigação sanguínea , Lesões Relacionadas à Guerra/complicações , Lesões Relacionadas à Guerra/cirurgia
4.
J Stroke Cerebrovasc Dis ; 29(8): 104983, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32689651
5.
J Endovasc Ther ; 27(5): 801-804, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32431245

RESUMO

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.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Isquemia do Cordão Espinal/terapia , Medula Espinal/irrigação sanguínea , Stents , Idoso , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/fisiopatologia , Doença Crônica , Humanos , Masculino , Fluxo Sanguíneo Regional , Isquemia do Cordão Espinal/diagnóstico por imagem , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Resultado do Tratamento , Grau de Desobstrução Vascular
6.
J Endovasc Ther ; 27(5): 764-768, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32452238

RESUMO

Purpose: To describe a new custom-made thoracic device able to seal against the aortic wall and occlude intercostal arteries for spinal cord preconditioning during the first thoracic stage of a thoracoabdominal endovascular repair. Technique: The custom-made device, based on the Zenith Alpha stent-graft, combines different features from 2 previously described devices: the outer part is designed with a bell-bottom configuration similar to the "Embo" stent-graft, while the inner part mimics the "2 in 1" design. The outer stent-graft is designed to span the entire length of the thoracic aorta and cover as many intercostal arteries as possible during the first stage to effectively precondition the spinal cord. The sutured inner component is customizable in diameter and 20 to 40 mm shorter than the outer stent-graft. The technique has been used in 5 patients. Conclusion: The use of this new custom-made thoracic stent-graft might represent an additional tool for effectively preconditioning the spinal cord during fenestrated and branched staged procedures whenever a proximal thoracic proximal component is needed.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Desenho de Prótese , Isquemia do Cordão Espinal/prevenção & controle , Medula Espinal/irrigação sanguínea , Stents , Idoso , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Masculino , Fluxo Sanguíneo Regional , Fatores de Risco , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
7.
J Clin Neurosci ; 77: 222-224, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32409214

RESUMO

Fibrocartilaginous embolism (FCE) is a rare and probably under diagnosed cause of spinal cord infarction presumably due to acute embolization of nucleus pulposus fragments into the spinal circulation. Concomitant cerebral involvement is much rarer and often asymptomatic. Although the definitive diagnosis is histologic, certain criteria have been proposed to support the diagnosis in living patients, such as absence of vascular risk factors, acute onset or antecedent of valsalva maneuver before the episode and the exclusion of potential differential diagnoses. A 56 years-old patient, without any medical history was referred for sudden back pain while carrying heavy load at work. Clinical examination showed a Brown-Sequard syndrome. Brain and spine MRI disclosed spinal cord infarction at the C4-C5 level associated with brain infarctions involving exclusively the vertebrobasilar circulation. The exhaustive etiological assessment was normal. In our case, the acute symptoms onset, the clinical and imaging data and lack of evidence for other plausible diagnoses in the setting of a valsalva-like maneuver are highly suggestive of FCE diagnosis.


Assuntos
Encéfalo/irrigação sanguínea , Doenças das Cartilagens/complicações , Embolia/complicações , Infarto/etiologia , Medula Espinal/irrigação sanguínea , Síndrome de Brown-Séquard/etiologia , Doenças das Cartilagens/diagnóstico , Doenças das Cartilagens/patologia , Diagnóstico Diferencial , Embolia/diagnóstico , Embolia/patologia , Humanos , Infarto/diagnóstico , Infarto/patologia , Imagem por Ressonância Magnética/efeitos adversos , Masculino , Pessoa de Meia-Idade , Medula Espinal/patologia
8.
Spine Deform ; 8(5): 1075-1080, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32274769

RESUMO

STUDY DESIGN: A multicenter retrospective IRB exempt case series analyzing clinical and radiographical data of patients treated by three surgeons over the past two decades was conducted. OBJECTIVE: To examine the factors involved in the development of quadriparesis in patients who underwent posterior spinal fusion for scoliosis. Delayed spinal cord infarcts usually present at the region of instrumentation according to reports from the Scoliosis Research Society. Nonetheless, there is a lack of data regarding factors associated with delayed quadriparesis following posterior spinal fusion METHODS: Evaluated variables were age, Cobb angle, blood loss, and curve correction percentage. Postoperative imaging was also evaluated to determine factors indicative of the etiology of the quadriparesis. RESULTS: Eight patients presented delayed postoperative quadriparesis. All patients had a postoperative examination equal to that of baseline. The first patient deteriorated at 6 h postoperatively and the most delayed patient presented 4 days postoperatively. Six patients had neuromuscular disorders and 2 had adolescent idiopathic scoliosis. Mean age was 13.7, mean curve magnitude was 78.7°, mean percent curve correction was 71% and the mean estimated blood loss was 1185 cc. Seven of eight patients had documented peri- or postoperative hypotension. CONCLUSIONS: Cervical infarction is the likely cause of delayed quadriparesis after posterior spinal fusion. Even though the underlying etiology continues to be unclear, postoperative hypotension, curve magnitude, percent curve correction, and the presence of cervical kyphosis/stenosis may be contributory and need to be closely evaluated. LEVEL OF EVIDENCE: IV, Case Series.


Assuntos
Quadriplegia/etiologia , Escoliose/cirurgia , Fusão Vertebral/efeitos adversos , Fusão Vertebral/instrumentação , Adolescente , Criança , Feminino , Humanos , Infarto/etiologia , Imagem por Ressonância Magnética , Masculino , Estudos Multicêntricos como Assunto , Quadriplegia/diagnóstico por imagem , Estudos Retrospectivos , Escoliose/diagnóstico por imagem , Medula Espinal/irrigação sanguínea , Fatores de Tempo
10.
J Endovasc Ther ; 27(2): 221-227, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32075487

RESUMO

Purpose: To describe a possible application of thoracic false lumen occlusion techniques with a Candy-Plug occluder to induce false lumen thrombosis for preconditioning the spinal cord during staged fenestrated repair of postdissecting thoracoabdominal aneurysms. Technique: A Candy-Plug occluder is deployed within the thoracic false lumen after proximal entry tear coverage with a standard thoracic stent-graft during staged repair of postdissecting thoracoabdominal aneurysms. The blockade of thoracic false lumen retrograde reperfusion from distal entry tears induces a controlled thrombosis of both the thoracic false lumen and intercostal arteries. Then, when the fenestrated device is delivered 4 to 6 weeks later, the procedure is completed with standard techniques according to the staging protocols of individual centers. Conclusion: A new possible application of a Candy-Plug false lumen occlusion technique might be an intermediate procedure aimed at preconditioning the spinal cord by occluding the thoracic false lumen during complex staged fenestrated thoracoabdominal repairs.


Assuntos
Aneurisma Dissecante/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/instrumentação , Isquemia do Cordão Espinal/prevenção & controle , Medula Espinal/irrigação sanguínea , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/fisiopatologia , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/fisiopatologia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fluxo Sanguíneo Regional , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
13.
AJNR Am J Neuroradiol ; 41(2): 357-363, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31919141

RESUMO

BACKGROUND AND PURPOSE: The impact of various radiologic and clinical features on the long-term outcome in spinal dural arteriovenous fistulas is still unclear; thus, they are the purpose of this study. MATERIALS AND METHODS: We retrospectively analyzed our medical data base for all patients treated for spinal dural arteriovenous fistula in our institution between 2006 and 2016. Patient age, neurologic status at the time of diagnosis, the duration of symptoms from onset to diagnosis, and follow-up information were evaluated. The extent of medullary T2WI hyperintensity, intramedullary contrast enhancement, and elongation of perimedullary veins on MR imaging at the time of diagnosis were additionally analyzed. RESULTS: Data for long-term outcome analysis were available in 40 patients with a mean follow-up of 52 months (median, 50.5 months; range, 3-159 months). The mean age at the time of diagnosis was 69.27 ± 9 years (median, 71 years; range, 53-84 years) with a male predominance (n = 32; 80%). The mean duration of symptoms was 20.2 months (median, 10 months; range, 1-120 months). Shorter duration of symptoms at the time of diagnosis was significantly correlated with better outcome of symptoms (P < .05). CONCLUSIONS: Spinal dural arteriovenous fistulas are characterized by interindividually variable clinical presentations, which make a determination of specific predictors for long-term outcome more difficult. Fast and sufficient diagnosis might result in a better outcome after treatment. The diagnosis of spinal dural arteriovenous fistula remains markedly delayed, reflecting an ongoing lack of knowledge and awareness among treating physicians of this rare-but-serious disease.


Assuntos
Malformações Vasculares do Sistema Nervoso Central/diagnóstico , Malformações Vasculares do Sistema Nervoso Central/terapia , Diagnóstico Tardio , Doenças da Medula Espinal/diagnóstico , Doenças da Medula Espinal/terapia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medula Espinal/irrigação sanguínea , Medula Espinal/patologia
14.
World Neurosurg ; 133: 314-317, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31648054

RESUMO

BACKGROUND: The adult spinal cord is typically resistant to hypoxic-ischemic injury because of collateral blood supply; however, congenital or acquired stenosis may result in baseline maximal vasodilation, such as superimposed hemodynamic stresses, that cannot be accommodated, leaving the spinal cord vulnerable to ischemic injury. We present a rare case of spinal cord hypoxic-ischemic injury in an adult with underlying cervical spinal stenosis. CASE DESCRIPTION: A 37-year-old man with a history of morbid obesity, diabetes mellitus, hypertension, and obstructive sleep apnea presented after developing progressive weakness in the extremities. Preoperative computed tomography myelography demonstrated ossification of the posterior longitudinal ligament and severe spinal canal narrowing. Approximately 1 week after posterior decompression, the patient experienced spinal hypoxic-ischemic injury. Imaging revealed cord expansion and abnormal T2 signal intensity. Axial diffusion tensor images of the brain revealed delayed ischemic leukoencephalopathy with restricted diffusion in the cerebral cortex and deep white matter; this led to the decision to withdraw care, and the patient died. CONCLUSIONS: We hypothesize that vascular dysregulation due to cervical stenosis made the cord parenchyma vulnerable to hypoxic and/or hypoperfusion stresses.


Assuntos
Descompressão Cirúrgica/efeitos adversos , Isquemia/etiologia , Leucoencefalopatias/etiologia , Ossificação do Ligamento Longitudinal Posterior/cirurgia , Medula Espinal/irrigação sanguínea , Estenose Espinal/cirurgia , Adulto , Evolução Fatal , Humanos , Isquemia/diagnóstico por imagem , Leucoencefalopatias/diagnóstico por imagem , Masculino , Ossificação do Ligamento Longitudinal Posterior/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Medula Espinal/diagnóstico por imagem , Estenose Espinal/diagnóstico por imagem
15.
J Thorac Cardiovasc Surg ; 159(3): 813-824.e1, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31030961

RESUMO

OBJECTIVES: Delayed paraplegia developed postoperatively after thoracoabdominal aneurysm surgery is primarily associated with spinal cord ischemia/reperfusion injury. Our previous study suggested that spinal cord stimulation postconditioning protected the spinal cord from ischemia/reperfusion injury through microglia inhibition. In this study, we further investigated whether α7 nicotinic acetylcholine receptors were involved in the neuroprotective mechanism of spinal cord stimulation. METHODS: Rabbits were randomly assigned to sham, control, 2 Hz, α-bungarotoxin, and 2 Hz-α-bungarotoxin groups (n = 24/group). Transient spinal cord ischemia was performed on all rabbits except rabbits in the sham group. Rabbits in the control group received no further intervention, rabbits in the 2 Hz group were given 2 Hz spinal cord stimulation, rabbits in the α-bungarotoxin group received prescribed intrathecal α-bungarotoxin (α-bungarotoxin, a specific α7 nicotinic acetylcholine receptor antagonist) injections, and rabbits in the 2 Hz-α-bungarotoxin group received both α-bungarotoxin injections and 2 Hz spinal cord stimulation. Hind-limb neurologic function was assessed, and spinal cord histologic examination, terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling staining, and microglia staining were performed at 8 hours, 1 day, 3 days, and 7 days of reperfusion. RESULTS: Rabbits in the 2 Hz group had significantly better neurologic functions, more α-motor neurons, and lower terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling-positive neuron rates and microglia area/anterior horn area ratios (microglia area ratios) than the control group. The neurologic functions of the α-bungarotoxin group were significantly worse than those of the control group, whereas other results were not significantly different from the control group. The results of the 2 Hz-α-bungarotoxin group were insignificant to the control group except for the terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling-positive neuron rates, which were significantly lower than in the control group. CONCLUSIONS: The neuroprotective effects of spinal cord stimulation postconditioning against spinal cord ischemia/reperfusion injury were partially mediated by activating α7 nicotinic acetylcholine receptors.


Assuntos
Microglia/metabolismo , Músculo Esquelético/inervação , Paraplegia/prevenção & controle , Traumatismo por Reperfusão/prevenção & controle , Isquemia do Cordão Espinal/prevenção & controle , Estimulação da Medula Espinal , Medula Espinal/irrigação sanguínea , Receptor Nicotínico de Acetilcolina alfa7/metabolismo , Animais , Apoptose , Modelos Animais de Doenças , Membro Posterior , Masculino , Microglia/patologia , Paraplegia/metabolismo , Paraplegia/patologia , Paraplegia/fisiopatologia , Coelhos , Traumatismo por Reperfusão/metabolismo , Traumatismo por Reperfusão/patologia , Traumatismo por Reperfusão/fisiopatologia , Isquemia do Cordão Espinal/metabolismo , Isquemia do Cordão Espinal/patologia , Isquemia do Cordão Espinal/fisiopatologia , Fatores de Tempo
16.
World Neurosurg ; 133: e391-e396, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31526882

RESUMO

OBJECTIVE: We sought to report the safety of implementation of a novel standard of care protocol using spinal cord perfusion pressure (SCPP) maintenance for managing traumatic spinal cord injury (SCI) in lieu of mean arterial pressure goals at a U.S. Level I trauma center. METHODS: Starting in December 2017, blunt SCI patients presenting <24 hours after injury with admission American Spinal Injury Association Impairment Scale (AIS) A-C (or AIS D at neurosurgeon discretion) received lumbar subarachnoid drain (LSAD) placement for SCPP monitoring in the intensive care unit and were included in the TRACK-SCI (Transforming Research and Clinical Knowledge in Spinal Cord Injury) data registry. This SCPP protocol comprises standard care at our institution. SCPPs were monitored for 5 days (goal ≥65 mm Hg) achieved through intravenous fluids and vasopressor support. AISs were assessed at admission and day 7. RESULTS: Fifteen patients enrolled to date were aged 60.5 ± 17 years. Injury levels were 93.3% (cervical) and 6.7% (thoracic). Admission AIS was 20.0%/20.0%/26.7%/33.3% for A/B/C/D. All patients maintained mean SCPP ≥65 mm Hg during monitoring. Fourteen of 15 cases required surgical decompression and stabilization with time to surgery 8.8 ± 7.1 hours (71.4% <12 hours). At day 7, 33.3% overall and 50% of initial AIS A-C had an improved AIS. Length of stay was 14.7 ± 8.3 days. None had LSAD-related complications. There were 7 respiratory complications. One patient expired after transfer to comfort care. CONCLUSIONS: In our initial experience of 15 patients with acute SCI, standardized SCPP goal-directed care based on LSAD monitoring for 5 days was feasible. There were no SCPP-related complications. This is the first report of SCPP implementation as clinical standard of care in acute SCI.


Assuntos
Pressão do Líquido Cefalorraquidiano , Traumatismos da Medula Espinal/terapia , Padrão de Cuidado , Idoso , Vértebras Cervicais/cirurgia , Protocolos Clínicos , Terapia Combinada , Descompressão Cirúrgica , Drenagem , Hidratação , Humanos , Infusões Intravenosas , Isquemia/prevenção & controle , Laminectomia , Pessoa de Meia-Idade , Medula Espinal/irrigação sanguínea , Traumatismos da Medula Espinal/fisiopatologia , Traumatismos da Medula Espinal/cirurgia , Vértebras Torácicas/cirurgia , Centros de Traumatologia , Resultado do Tratamento , Vasoconstritores/uso terapêutico
17.
J Neurosurg ; 131(6): 1690-1701, 2019 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-31786544

RESUMO

Neuroendovascular surgery and interventional neuroradiology both describe the catheter-based (most often) endovascular diagnosis and treatment of vascular lesions affecting the brain and spinal cord. This article traces the evolution of these techniques and their current role as the dominant and frequently standard approach for many of these conditions. The article also discusses the important changes that have been brought to bear on open cerebrovascular neurosurgery by neuroendovascular surgery and their effects on resident and fellow training and describes new concepts for clinical care.


Assuntos
Transtornos Cerebrovasculares/cirurgia , Procedimentos Endovasculares/métodos , Procedimentos Neurocirúrgicos/métodos , Encéfalo/irrigação sanguínea , Encéfalo/cirurgia , Transtornos Cerebrovasculares/diagnóstico , Procedimentos Endovasculares/tendências , Humanos , Procedimentos Neurocirúrgicos/tendências , Medula Espinal/irrigação sanguínea , Medula Espinal/cirurgia
18.
BMC Neurol ; 19(1): 321, 2019 Dec 12.
Artigo em Inglês | MEDLINE | ID: mdl-31830940

RESUMO

BACKGROUND: Spinal cord infarction (SCI) is rarely caused by vertebral artery dissection (VAD), which is an important cause of posterior circulation stroke in young and middle-aged patients. We report the case of a middle-aged patient without obvious risk factors for atherosclerosis who had SCI from right VAD. CASE PRESENTATION: An otherwise healthy 40-year-old man presented with acute right-sided body weakness. Six days earlier, he had experienced posterior neck pain without obvious inducement. Neurologic examination revealed a right Brown-Séquard syndrome. Magnetic resonance imaging (MRI) of the head was normal. Further, cervical spine MRI showed spinal cord infarction (SCI) on the right at the C1-C3 level. Three-dimensional high-resolution MRI (3D HR-MRI) volumetric isotropic turbo spin echo acquisition (VISTA) scan showed evidence of vertebral artery dissection (VAD). The patient was significantly relieved of symptoms and demonstrated negative imaging findings after therapy with anticoagulation (AC) and antiplatelets (AP) for 3 months. CONCLUSIONS: The possibility of vertebral artery dissection (VAD) should be considered in the case of young and middle-aged patients without obvious risk factors for atherosclerosis. Furthermore the VISTA black blood sequence plays an important role in the pathological diagnosis of vertebral artery stenosis. Early correct diagnosis and active therapy are crucial to the prognosis.


Assuntos
Síndrome de Brown-Séquard/etiologia , Infarto/etiologia , Medula Espinal/irrigação sanguínea , Dissecação da Artéria Vertebral/complicações , Adulto , Humanos , Masculino , Medula Espinal/patologia , Doenças da Medula Espinal/etiologia
19.
Proc Natl Acad Sci U S A ; 116(51): 26029-26037, 2019 12 17.
Artigo em Inglês | MEDLINE | ID: mdl-31772011

RESUMO

Hypoxic preconditioning reduces disease severity in a mouse model of multiple sclerosis (MS), in part by enhancing the barrier properties of spinal cord blood vessels. Because other studies have shown that similar levels of hypoxia transiently increase permeability of central nervous system (CNS) blood vessels, the goal of this study was to define the impact of chronic mild hypoxia (CMH, 8% O2) on the integrity of spinal cord blood vessels and the responses of neighboring glial cells. Using extravascular fibrinogen as a marker of vascular disruption, we found that CMH triggered transient vascular leak in spinal cord blood vessels, particularly in white matter, which was associated with clustering and activation of Mac-1-positive microglia around disrupted vessels. Microglial depletion with the colony stimulating factor-1 receptor (CSF-1R) inhibitor PLX5622, while having no effect under normoxic conditions, profoundly increased vascular leak in both white and gray matter during CMH, and this was associated with disruption of astrocyte-vascular coupling and enhanced loss of tight junction proteins. Microglial repair of leaky blood vessels was blocked by a peptide that inhibits the interaction between fibrinogen and its Mac-1 integrin receptor. These findings highlight an important role for microglia in maintaining vascular integrity in the hypoxic spinal cord and suggest that a fibrinogen-Mac-1 interaction underpins this response. As relative hypoxia is experienced in many situations including high altitude, lung disease, obstructive sleep apnea, and age-related CNS ischemia/hypoxia, our findings have important implications regarding the critical role of microglia in maintaining vascular integrity in the CNS.


Assuntos
Hipóxia/metabolismo , Microglia/metabolismo , Esclerose Múltipla/metabolismo , Medula Espinal/irrigação sanguínea , Medula Espinal/metabolismo , Animais , Antígenos de Superfície/metabolismo , Astrócitos/metabolismo , Sistema Nervoso Central/irrigação sanguínea , Modelos Animais de Doenças , Endotélio/irrigação sanguínea , Endotélio/metabolismo , Feminino , Fibrinogênio , Substância Cinzenta/metabolismo , Isquemia/metabolismo , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Esclerose Múltipla/complicações , Neuroglia , Compostos Orgânicos/antagonistas & inibidores , Receptores de Fator Estimulador das Colônias de Granulócitos e Macrófagos/efeitos dos fármacos , Receptores de Fator Estimulador das Colônias de Granulócitos e Macrófagos/metabolismo , Substância Branca/metabolismo
20.
Neuroimaging Clin N Am ; 29(4): 615-633, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31677734

RESUMO

This article reviews the arterial and venous anatomy of the spine and spinal cord. Special emphasis is placed on vessels critical to the conduct and interpretation of spinal angiography, notably the intersegmental artery and its cranial and caudal derivatives: the vertebral, supreme intercostal, and sacral arteries.


Assuntos
Angiografia/métodos , Medula Espinal/irrigação sanguínea , Medula Espinal/diagnóstico por imagem , Humanos
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