Asian Cardiovasc Thorac Ann 2006;14:e106-e107
© 2006 Asia Publishing EXchange Ltd
Treatment Methods for Spinal Cord Injury Caused by Acute Type B Aortic Dissection
Yasuaki Fujisawa, MD,
Kiyofumi Morishita, MD,
Johji Fukada, MD,
Nobuyoshi Kawaharada, MD,
Yoshikazu Hachiro, MD,
Tomio Abe, MD
Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
For reprint information contact: Yasuaki Fujisawa, MD Tel: 81 11 611 2111 (Ext 3312) Fax: 81 11 613 7318 Email: fuji{at}sapmed.ac.jp, Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo 0608543, Japan.
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ABSTRACT
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Acute distal aortic dissection rarely causes spinal cord ischemia presenting with paraplegia or paraparesis. Spinal cord involvement has poor outcomes, and there is no established effective treatment for this disorder. In this report we describe the acute conservative treatment of two cases of paraplegia/paraparesis due to acute type B aortic dissection. Early reversal of lower-limb dysmobility was achieved.
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CASE REPORTS
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CASE 1
A 65-year-old hypertensive man came to our hospital with severe back pain and a cataplectic attack of the lower extremities. Computed tomography (CT) demonstrated an aortic dissection of the descending aorta with thrombosed false lumen. His blood pressure was 180/110 mm Hg. He had paraplegia and dissociated sensory loss on the lower side of the umbilical region. The damaged region of the spinal cord was diagnosed at the level of Th10. He immediately underwent cerebrospinal fluid drainage (CSFD), and the cerebrospinal fluid pressure was maintained at 10 cm H2O. Additionally, a continuous intravenous infusion of naloxone (0.01µg·kg–1·min–1) was started, and his systolic blood pressure was maintained between 120–140 mm Hg using nicardipine hydrochloride. On the following day, the muscle strength in his legs slightly improved. The subsequent day the infusion of naloxone was terminated, and the CSFD tube was removed. Subsequently, the dysfunctions in the lower extremities progressively improved. A couple of weeks after onset, the patient was able to stand and walk with a caster.
CASE 2
A 69-year-old man developed an acute onset of severe back pain and presented to our hospital. A chest CT scan showed Type B dissecting descending aorta with a partially thrombosed false lumen. His blood pressure was 190/100 mm Hg. Intravenous antihypertensive medication was immediately started. The following morning, the patient experienced slight lower limb weakness on the left side, which subsequently led to gradual weakness. A few hours later, he suffered complete paralysis below his left hip and dissociated sensory loss on the left lower leg. The damaged region of the spinal cord was diagnosed at the level of Th9. An emergency chest CT revealed a massive hematoma around the ascending aorta. This finding supported the retrograde progression of aortic dissection and the increased potential for rupture. Therefore, we decided to perform an emergency operation by endovascular stent-grafting for closure of the aortic dissection entry. Before the operation, a CSFD tube was inserted immediately and the pressure was kept at 10 cm H2O to treat preoperative spinal cord involvement. The entry originated in the upper descending thoracic aorta. We placed a stent-graft via the right femoral artery. At the end of the operation, a continuous intravenous infusion of naloxone (0.01µg·kg–1·min–1) was started, and the systolic blood pressure was maintained between 120–140 mm Hg. The following day, the muscle strength in his left leg improved slightly. The infusion of naloxone and CSFD was continued for 2 days after the operation. The movement of his left lower extremity improved remarkably. A week after the onset of paraparesis, the patient was able to stand on his own.
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DISCUSSION
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Paraplegia or paraparesis is a serious complication of distal aortic dissection. Unfortunately however, effective treatments for spinal ischemia have not been established yet. Therefore, rehabilitative exercise is a common treatment for muscular weakness of the lower extremities. In these reported cases, we managed the condition acutely through 1: CSFD, 2: administration of naloxone hydrochloride and 3: regulation of systemic blood pressure.
1: CSFD
Cerebrospinal fluid drainage is often used for the treatment of postoperative spinal cord injury after thoracoabdominal aortic graft replacement, and many clinicians have proved the clinical advantage.1,2 After the initial spinal ischemia, levels of endogenous opiates, specifically ß-endorphin, increase markedly and remain elevated for 24 to 36 hours in the cerebrospinal fluid.3 Reportedly, the opiates reduce cerebral blood flow, increase vascular resistance, depress the firing rate of single neurons, and depress the central nervous system acetylcoline turnover.4,5 The purpose of CSFD is to reduce the degree of ischemic damage by removing endogenous opiates from the spinal fluid.
2: Administration of naloxone
Naloxone produces various effects such as improvement of spinal cord blood flow, inhibition of proteolysis, stabilization of lysosomal membranes, and so on.6
3: Regulation of blood pressure
We believe regulating systemic blood pressure between 120–140 mm Hg is important in order to prevent decrease of the blood flow to the spinal cord by excessive antihypertensive therapy. Cerebrospinal fluid drainage and Naloxone infusion are often used for treatment of postoperative spinal cord injury after thoracoabdominal aortic graft replacement, with many clinicians reporting both experimental and clinical effects.
In the acute phase of sudden spinal disorder, the patient displays symptoms of spinal shock for a few days to several weeks. We believe that aggressive acute treatment as described above is effective for accelerating the recovery from spinal shock. Cerebrospinal fluid drainage was ceased the day after the spinal shock began to subside (in particular, when movement in the leg appeared) in order to avoid complications caused by CSFD (e.g. cerebral meningitis, epidural hematoma or abscess). Due to the above-mentioned levels of endogenous opiates after the initial spinal ischemia, naloxone treatment was ended after a few days. In these reported cases, it ended simultaneously with the removal of the CSFD tube. In case 2, the endovascular therapy for entry closure possibly increased blood flow into the true lumen including the intercostal arteries, and improved the spinal blood flow.
The prognosis of spinal cord injury caused by acute type B aortic dissection was not elucidated on account of its rareness. This disorder may progress to complete paraplegia, with effective treatments not yet established. Therefore, we believe that it is important to perform every possible treatment aggressively. In order to reduce spinal shock, acute treatment should be started as soon as practicably possible after the onset.
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Should we consider surgical intervention for spinal cord ischemia due to acute type B aortic dissection?
Eur. J. Cardiothorac. Surg.,
March 1, 2009;
35(3):
547 - 549.
[Abstract]
[Full Text]
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