Ann Thorac Surg 2001;72:1389-1391
© 2001 The Society of Thoracic Surgeons
Case report
Delayed postoperative paraplegia complicating repair of type A dissection
Benjamin Medalion, MDa,
Othman Bder, MDa,
Amram J. Cohen, MDa,
Eli Hauptman, MDa,
Arie Schachner, MDa
a Department of Cardiothoracic Surgery, The E. Wolfson Medical Center, Holon, Israel
Accepted for publication October 17, 2000.
Address reprint requests to Dr Medalion, Department of Cardiothoracic Surgery, The E. Wolfson Medical Center, PO Box 5, Holon 58100, Israel
e-mail: bmedalion{at}yahoo.com
 |
Abstract
|
|---|
We describe the very rare event of delayed transient paraplegia after repair of type A dissection of the aorta and discuss therapeutic options. We also suggest insertion of a spinal catheter as soon as there are signs or symptoms of spinal cord injury to drain spinal fluid and maximize the effect of elevated spinal cord perfusion pressure.
|
Introduction
|
|---|
Paraplegia is a known complication after repair of descending thoracic and thoracoabdominal dissections of the aorta [1]. Paraplegia in association with type A dissection is rare and usually is present preoperatively [2, 3]. Postoperative paraplegia that was not present preoperatively, complicating a repair of type A dissection of the aorta, is extremely rare [4]. We describe a case of delayed transient paraplegia after repair of type A dissection of the aorta.
A 59-year-old hypertensive man was admitted to the hospital with chest and abdominal pain. His blood pressure was 100/70 mm Hg with a pulse of 100 per minute. The patient had normal and equal femoral pulses. ECG results were normal. A chest roentgenogram revealed a widened mediastinum, and computed tomography (CT) demonstrated an aortic dissection beginning just above the sinotubular junction and extending down to the iliac arteries (Fig 1). Moderate pericardial effusion was noted. The patient was rushed to the operating room where transesophageal echocardiography confirmed the previous findings, with no evidence of aortic valve insufficiency. The exploration was through a median sternotomy, and the patient was placed on cardiopulmonary bypass by way of the left femoral artery and right atrium. Under deep hypothermic circulatory arrest, the ascending aorta was replaced from the sinotubular junction to the level of the innominate artery with a 30-mm woven Dacron (D. R. Bard, Haverhill, PA) graft. The dissected layers of the aortic wall were glued together with fibrin glue and the graft was sewn in place with continuous 4-0 Prolene (Ethicon, Somerville, NJ). The operative and immediate postoperative courses were uneventful. The patient regained consciousness, and moved all his limbs. He was extubated 12 hours postoperatively. At 24 hours after the operation, paraparesis developed in the patient that progressed to paraplegia within 2 hours. CT performed at that time showed an intact repair. From the level of the mid-descending thoracic aorta, two lumens could be seen filled with contrast medium (Fig 2). Angiography was performed that showed the visceral vessels originating from the true lumen, and spinal vessels were identified as coming from the false lumen. There was no pressure gradient between the 2 lumen at any level along the dissection. A catheter was inserted into the spinal canal and a pressure of 15 mm Hg was measured. Spinal fluid was drained as necessary to maintain the spinal pressure at 10 mm Hg for 24 hours. The patient recovered gradually, and started to move his legs after 3 days. He underwent extensive physiotherapy and was discharged to a rehabilitation center 20 days after the operation. At that time, he regained the sensory function of his legs, but could move his legs only slightly. At 6 months follow-up, the patient was doing well and was walking independently. His left leg was weaker than the right leg.
View larger version (79K):
[in this window]
[in a new window]
|
Fig 1. Preoperative CT scan of the chest showing the dissections of both ascending and descending aorta.
|
|
View larger version (98K):
[in this window]
[in a new window]
|
Fig 2. Postoperative CT scan of the chest demonstrating an intact repair of the ascending aorta and a dissection of the descending aorta.
|
|
|
Comment
|
|---|
Paraplegia after repair of type A dissection is rare [4]. Thrombosis of the spinal artery has been suggested as a cause [4]. In the current case, although a recurrent tear in the ascending aorta was excluded, communication between the true and false lumen existed at the descending aorta. It is unclear whether this tear occurred postoperatively or was part of the original dissection. Although not described for paraplegia, percutaneous balloon fenestration of the intimal flap has been applied successfully in some patients with acute aortic dissection who suffered life-threatening ischemic complications [5]. Because, in this case, there was no pressure gradient between the 2 lumens at any level along the dissection, fenestration did not seem to add any benefit and, hence, was not performed. The cause of paraplegia is likely to be related to the dissection in the descending aorta, whether it is secondary to an embolic event, ischemia, or flap closure of the origin of a spinal artery. Delayed paraplegia may be associated with a precipitating episode, like hypotension, hypovolemia or pneumothorax, leading to spinal cord ischemia [6]. However, our patient did not suffer from any of those problems. The fact that the patient recovered almost complete mobility mitigates against an embolic event. Catheter manipulation of the false lumen may have elevated the flap from the spinal artery to regenerate the blood flow. Alternatively, the attempt to keep the spinal pressure low during the first 24 hours may have elevated the perfusion pressure of the spinal cord. It has been shown that spinal fluid drainage during repair of thoracoabdominal aneurysms reduces neurologic complications, especially in delayed paraplegia [6–8].
This case demonstrates our lack of understanding and diversity of the individual spinal cord’s perfusion, and the unpredictable outcome of injury to the cord. A faster and more complete resolution of delayed paraplegia, after initiating spinal cord drainage, were described [6, 8]. There was a long interval between spinal fluid drainage and noticeable neurologic improvement, making it difficult to assess if recovery was directly attributable to the drainage. Nevertheless, in view of the fact that the insertion of a spinal catheter is a relatively safe and easy-to-perform bedside procedure, we suggest the insertion of a spinal catheter as soon as any signs or symptoms of spinal cord injury occur, to drain the spinal fluid and maximize the effect of elevated spinal cord perfusion. Although not used in this case, other strategies for treating paraplegia, like the use of mannitol, steroids, or naloxone, may be considered for use concomitantly.
|
References
|
|---|
-
Coselli J.S., LeMaire S.A., de Figueiredo L.P., Kirby R.P. Paraplegia after thoracoabdominal aortic aneurysm repair: is dissection a risk factor?. Ann Thorac Surg 1997;63:28-35.[Abstract/Free Full Text]
-
Zull D.N., Cydulka R. Acute paraplegia: a presenting manifestation of aortic dissection. Am J Med 1988;84:765-770.[Medline]
-
Tanaka T., Uemura K., Sugiura M., et al. Transient paraplegia caused by acute aortic dissection: Case report. Neurol Med Chir Tokyo 1990;30:54-58.[Medline]
-
Sakurada T., Kikuchi Y., Nakashima S., Koushima R., Kondo N., Kusajima K. A case of paraplegia after graft replacement of the ascending aorta and the total aortic arch for the DeBakey type I acute aortic dissection. Kyobu Geka 1997;50:1041-1044.[Medline]
-
Slonim S.M., Miller D.C., Mitchell R.S., et al. Percutaneous balloon fenestration and stenting for life-threatening ischemic complications in patients with acute aortic dissection. J Thorac Cardiovasc Surg 1999;117:1118-1126.[Abstract/Free Full Text]
-
Hollier L.H., Symmonds J.B., Pairolero P.C., et al. Thoracoabdominal aortic aneurysm repair: analysis of postoperative morbidity. Arch Surg 1988;123:871-875.[Abstract/Free Full Text]
-
Safi H.J., Hess K.R., Randel M., et al. Cerebrospinal fluid drainage and distal aortic perfusion: reducing neurologic complications in repair of thoracoabdominal aortic aneurysm types I and II. J Vasc Surg 1996;23:223-228.[Medline]
-
Hill A.B., Kalman P.G., Johnston K.W., Vosu H.A. Reversal of delayed paraplegia after thoracic aortic surgery with cerebrospinal fluid drainage. J Vasc Surg 1994;20:315-317.[Medline]
This article has been cited by other articles:
|
|
|
|
 
E. Girdauskas, T. Kuntze, T. Walther, and F.-W. Mohr
Delayed paraplegia associated with vertebral necrosis after type A dissection surgery
Eur. J. Cardiothorac. Surg.,
January 1, 2008;
33(1):
121 - 123.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Y. Kawanishi, K. Okada, K. Nakagiri, A. Kitagawa, H. Tanaka, M. Matsumori, and Y. Okita
Three Cases of Newly Developed Paraplegia After Repairing Type A Acute Aortic Dissection
Ann. Thorac. Surg.,
November 1, 2007;
84(5):
1738 - 1740.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
