Painless aortic dissection presenting as spinal cord ischemia

Spinal Cord Ischemia Secondary to Aortic Dissection: Case Report with Literature Review for Different Clinical Presentations, Risk Factors, Radiological Findings, Therapeutic Modalities, and Outcome

Aortic dissection (AD) is a serious condition that causes transient or permanent neurological problems that include spinal cord ischemia (SCI), which occurs when AD extends into the descending aorta resulting in insufficient perfusion of segmental arteries that supplies the spinal cord. We report a 64-year-old male, presented with severe back pain, asymmetrical paresthesia, and weakness of both limbs, more in the left lower limb with loss of pinprick, temperature, and fine touch sensation on the lower left lower limb below the level of T5 with preserved proprioception and vibration and urine hesitancy. Computed tomography showed AD, Stanford type A, and spinal magnetic resonance imaging (MRI) showed hyperintense owl's eye sign at T5. The patient was diagnosed as anterior spinal artery syndrome secondary to an AD and referred for aortic surgical repair with good functional outcome. In our review to cases of SCI due to AD, it was more common in males above 55 years, pain only found in 47.8% of patients, with anterior cord syndrome on top of the clinical presentations, and hypertension is the most common risk factor. MRI spine showed thoracic location predominance. Surgical or endovascular repair especially for type A and complicated type B should be considered to avoid complications, and cerebrospinal fluid drainage is a very useful tool in reversing SCI specially if done early with favorable outcome. Only the old age is associated with increased risk of mortality. Early diagnosis and appropriate management are crucial for better outcome.

Usefulness of point-of-care ultrasound in the atypical presentation of aortic dissection: a case series and brief review of literature

Acute aortic dissection represents a surgical emergency that, in most cases, may present an atypical and non-specific clinic, making the diagnosis difficult and late. Computed tomography angiography represents the gold standard for diagnosis, but different ultrasound techniques are able to provide valuable additional information related to diagnosis, and optimize therapy and prognostic assessment. In this case series, we describe different atypical patterns of aortic dissection, associated to non-diagnostic D-Dimer levels. These atypical conditions escape recognized diagnostic algorithms for the diagnosis of aortic dissection, although the incidence of such events is far from negligible. A clinical approach in the emergency setting that provides for a systematic and standardized use of bedside ultrasound could help reduce the incidence of errors and diagnostic delay, addressing the gold standard instrumental diagnostics for the reference pathology.

Repetitive transient paraplegia caused by painless acute aortic dissection

Case

Making a precise diagnosis of type A acute aortic dissection (AAD) presenting with atypical symptoms might be challenging for clinicians. Misdiagnosis and misuse of thrombolytic therapy can have devastating consequences.

Outcome

Herein, we report a case of painless type A AAD complicated by transient leg paresthesia, which was successfully treated with surgery. On admission, sudden onset of right leg numbness and muscle weakness was the only clue toward the correct final diagnosis.

Conclusion

When patients present with vague neurological symptoms, physicians should not rule out the possibility of AAD until proven otherwise.

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

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

Aortic Dissection Presented as Paraparesis: A Case Report with Literature Review

One case of acute type B aortic dissection presented with paraparesis and retrosternal chest pain was treated conservatively with warfarin and blood pressure control with good recovery of symptoms. A literature review including 25 cases of aortic dissection presented with paraparesis/paraplegia from year 1980 to 2010 is also presented.

Acute aortic dissection presenting as painless paraplegia: a case report

BACKGROUND

Acute aortic dissection is an extreme emergency that is generally manifested by violent chest pain irradiating to a patient's back and abdomen. Paraplegia due to spinal cord ischemia and infarction as a presenting manifestation of aortic dissection has been found in 2 to 5% of patients. However, painless paraplegia is exceedingly rare and limited to a few case reports in the literature. We describe a new case with this unusual presentation of aortic dissection and here we emphasize that this condition must be considered in all patients with painless paraplegia.

CASE PRESENTATION

A 70-year-old Arab man with no previous known medical or surgical conditions was hospitalized for brutal heaviness of his lower limbs associated to urinary retention. A neurological examination revealed flaccid paraplegia without sensory disorder. His blood pressure and his pulse were in normal ranges. He was afebrile. His peripheral pulses were not checked. Laboratory investigations eliminated multiple organ failure. Spinal magnetic resonance imaging realized in emergency was normal. He had a cardiopulmonary arrest 1 day after his hospitalization. His autopsy report concluded a type A aortic dissection with an intimal tear at his aortic isthmus with intrapericardial rupture and extension to his intercostal and lumbar arteries.

CONCLUSIONS

Acute aortic dissection is an extreme emergency that can lead to death unless there is an early diagnosis. It must be considered in any patient with paraplegia even painless. Clinical examination has a major role to play in diagnosing this condition. Apart from the neurological examination, palpation of peripheral pulses and blood pressure measurements in all four limbs is of paramount importance. Then further investigations must be carried out consisting of aortic angiography by computed tomography or by magnetic resonance imaging.

Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery

BACKGROUND

During aortic aneurysm surgery, cross-clamping can lead to inadequate blood supply to the spinal cord resulting in neurological deficit. Cerebrospinal fluid drainage (CSFD) may increase the perfusion pressure to the spinal cord and hence reduce the risk of ischaemic spinal cord injury.

OBJECTIVES

To determine the effect of CSFD during thoracic and thoracoabdominal aortic aneurysm (TAAA) surgery on the risk of developing spinal cord injury.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched May 31 2012) and CENTRAL (2012, Issue 5) for publications describing randomised controlled trials of cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery. Reference lists of relevant articles were checked.

SELECTION CRITERIA

Randomised trials involving CSFD during thoracic and TAAA surgery.

DATA COLLECTION AND ANALYSIS

Both authors assessed the quality of trials independently. SNK extracted data and GS verified the data.

MAIN RESULTS

Three trials with a total of 287 participants operated on for Type I or II TAAA were included.In the first trial of 98 participants, neurological deficits in the lower extremities occurred in 14 (30%) of CSFD group and 17 (33%) controls. The deficit was observed within 24 hours of the operation in 21 (68%), and from three to 22 days in 10 (32%) participants. CSFD did not have a significant benefit in preventing ischaemic injury to the spinal cord.The second trial of 33 participants used a combination of CSFD and intrathecal papaverine. It showed a statistically significant reduction in the rate of postoperative neurological deficit (P = 0.039), compared to controls. Analysis was undertaken after only one third of the estimated sample size had entered the trial.In the third trial TAAA repair was performed on 145 participants. CSFD was initiated during the operation and continued for 48 hours after surgery. Paraplegia or paraparesis occurred in 9 of 74 participants (12.2%) in the control group versus 2 of 82 participants (2.7%) receiving CSFD (P = 0.03). Overall, CSFD resulted in an 80% reduction in the relative risk of postoperative deficits. Meta-analysis showed an odds ratio (OR) of 0.48 (95 % confidence interval (CI) 0.25 to 0.92). For CSFD-only trials, OR was 0.57 (95% CI 0.28 to 1.17) and for intention-to-treat analysis in CSFD-only studies, the OR remained unchanged.

AUTHORS' CONCLUSIONS

There are limited data supporting the role of CSFD in thoracic and thoracoabdominal aneurysm surgery for prevention of neurological injury. Further clinical and experimental studies are indicated.

Recovery of paraplegia after type B dissection due to spinal collateral recruitment

Acute paraplegia could be a symptom of aortic dissection due to sudden compromise of arterial spinal cord blood supply. Complete spontaneous neurologic recovery is possible and was observed in the present case 3 hours after symptom onset. Spontaneous spinal cord reperfusion after acute type B dissection was probably due to two main mechanisms. Reperfusion of false lumen and collateral vascular network recruitment, recently confirmed by anatomic animal studies, serve as potential explanations. Favorable evolution of acute paraplegia after aortic dissection exists, but prognosis is uncertain, probably due to individual variable anatomic distribution of spinal cord blood supply.

Painless dissecting aneurysm of the aorta presenting as simultaneous cerebral and spinal cord infarctions

Authors report a case of a painless acute dissecting aneurysm of the descending aorta in a patient who presented with unexplained hypotension followed by simultaneous paraplegia and right arm monoparesis. To our knowledge, case like this has not been reported previously. Magnetic resonance imaging of the brain and spine revealed hemodynamic cerebral infarction and extensive cord ischemia, respectively. Computerized tomography angiography confirmed a dissecting aneurysm of the descending aorta. The cause of the brain infarction may not have been embolic, but hemodynamic one. Dissection-induced hypotension may have elicited cerebral perfusion insufficiency. The cause of cord ischemia may be embolic or hemodynamic. The dissected aorta was successfully replaced into an artificial patch graft. The arm monoparesis was improved, but the paraplegia was not improved. In rare cases of brain and/or spinal cord infarction caused by painless acute dissecting aneurysm of the aorta, accurate diagnosis is critical because careless thrombolytic therapy can result in life-threatening bleeding.

Painless transient paraparesis as the solitary manifestation of aortic dissection

We present a 62-year-old man with acute and temporary paraparesis of the lower extremities as the solitary symptom of an anterior spinal artery syndrome caused by a type B aortic dissection. Ischemia of the spinal cord was confirmed by magnetic resonance imaging. Neurologic symptoms resolved completely within 6 hours and conservative treatment was successful up to 8 months follow-up. Our report illustrates that painless, transient neurologic deficit can be the only presenting symptom of acute aortic dissection and that aortic dissection should be part of the differential diagnosis of acute paraparesis.

Acute infrarenal aortic thrombosis presenting with flaccid paraplegia

STUDY DESIGN

This study is a case report.

OBJECTIVE

To report a case of a patient with paraplegia and low back pain, who was diagnosed with acute infrarenal aortic thrombosis.

SUMMARY OF BACKGROUND DATA

There have been few reports in the literature regarding acute aortic thrombosis presenting with paraplegia.

METHODS

A 56-year-old man was referred to our emergency department with flaccid paraplegia and low back pain. Clinical examination and imaging revealed acute infrarenal aortic thrombosis, with lower limb ischemia. The patient underwent transcutaneous embolectomy.

RESULTS

Despite successful revascularization, the patient finally died because of development of revascularization syndrome.

CONCLUSION

Acute aortic occlusion is a catastrophic event and may present with paraplegia, because of acute spinal cord ischemia. This can mislead the clinician to a wrong diagnosis and delay initiation of definite treatment.

Reversal of paraplegia following repair of an ascending aortic dissection

We report the case of a patient who presented with sudden onset of paraplegia following an acute ascending aortic dissection extending to the arch, descending, and abdominal aorta. The paraplegia was fully reversed following an emergent replacement of the ascending aorta and hemi-arch repair.

Acute aortic dissection: be aware of misdiagnosis

Background

Acute aortic dissection (AAD) is a life-threatening condition requiring immediate assessment and therapy. A patient suffering from AAD often presents with an insignificant or irrelevant medical history, giving rise to possible misdiagnosis. The aim of this retrospective study is to address the problem of misdiagnosing AD and the different imaging studies used.

Methods

From January 2000 to December 2004, 49 patients (41 men and 8 women, aged from 18–75 years old) presented to the Emergency Department of our hospital for different reasons and finally diagnosed with AAD. Fifteen of those patients suffered from arterial hypertension, one from giant cell arteritis and another patient from Marfan's syndrome. The diagnosis of AAD was made by chest X-ray, contrast enhanced computed tomography (CT), transthoracic echocardiography (TTE) and coronary angiography.

Results

Initial misdiagnosis occurred in fifteen patients (31%) later found to be suffering from AAD. The misdiagnosis was myocardial infarction in 12 patients and cerebral infarction in another three patients.

Conclusion

Aortic dissection may present with a variety of clinical manifestations, like syncope, chest pain, anuria, pulse deficits, abdominal pain, back pain, or acute congestive heart failure. Nearly a third of the patients found to be suffering from AD, were initially otherwise diagnosed. Key in the management of acute aortic dissection is to maintain a high level of suspicion for this diagnosis.

Acute aortic dissection presenting as painful paraplegia

Aortic dissection is a rare potentially life threatening condition. Neurological complications such as paraplegia as presenting manifestation of aortic dissection are exceedingly rare. We describe a 60-year-old man who presented with acute onset paraplegia with bladder involvement, constricting pain in the lower abdomen, bradycardia and succumbed rapidly within 14h of onset of symptoms. Autopsy revealed an unexpected cause of paraplegia with extensive aortic dissection extending from origin to iliac bifurcation (DeBakey type I). The aorta showed extensive atherosclerosis causing medial destruction and dissection. The spinal cord in the vulnerable watershed zone of T12-L1 downwards revealed ischemic softening. No infarcts were seen in other organs as he succumbed rapidly to cardiac tamponade. Acute aortic dissection presenting as paraplegia though rare, should be considered in patients presenting with sudden onset paraplegia with associated severe pain and absent pulses. Prompt diagnosis and timely intervention may help save life and limb.

Painless Aortic Dissection with Initial Symptom of Right Upper Extremity Weakness: A Case Report

Thoracic aortic dissection is a dangerous disease. It usually presents as severe chest or back pain. Symptoms resulting from aortic branch involvement may also be involved. Sometimes, it presents with atypical symptoms. Here, we report a patient who came to the emergency department (ED) because of acute onset of right upper limb weakness and numbness. Brain computed tomography (CT) was performed initially because cerebral vascular disease was suspected. Subsequently, angiography was performed as artery occlusion of the limb was found. The patient suddenly collapsed in the ED. Stanford type A acute aortic dissection was found by chest CT.

Aortic fenestration for chronic aortic dissection type B complicated by transient ischemic attacks of spinal cord

Spinal cord injury is a rare complication in patients with aortic dissection. The extrinsic arterial supply to the spinal cord, diminishing caudally, often becomes critically dependent on the great radicular artery (GRA) of Adamkiewicz at the thoracolumbar spine. There are no prior reports of spinal injury or ischemia caused by chronic aortic dissection. We report on a 51-year-old patient with chronic type B dissection of the aorta from below the subclavian takeoff through the iliac arteries, presented with multiple episodes of transient (1 to 5 minutes) spinal ischemic attacks, entailing sudden loss of motor and sensory functions in both legs, with collapse of the patient on the ground. GRA imaging acquired with 64-channel computed tomography angiography enabled aortic fenestration from T11 to L1, performed with supraceliac aortic cross-clamping (T8 to L2) via thoracoabdominal access. We critically appraise the pertinent literature.

Seeing the invisible: painless aortic dissection in the emergency setting

Acute dissection of the aorta can be one of the most dramatic cardiovascular emergencies. Classically, aortic dissection presents as sudden, severe chest, back, or abdominal pain that is characterised as ripping or tearing in nature. However, a timely diagnosis can be elusive in the event of an atypical presentation. In this report, the authors present two patients with painless aortic dissection who were misdiagnosed during their initial evaluation in the emergency department.

Acute abdominal aortic aneurysm rupture presenting as transient paralysis of the lower legs: A case report

This article describes the case of a 40-year-old man with transient paralysis of both legs as the major symptom of an acute abdominal aortic aneurysm rupture presumably due to the occlusion of blood flow to the conus medullaris.

Aortic disasters

TAD and AAA are two of the highest risk disease entities in emergency medicine. Emergency physicians should be vigilant in their approach to patients who have symptoms compatible with acute aortic disease. In chest and abdominal pain presentations, the chart must look like there was a search for the TAD and AAA. By having a sound knowledge of atypical cases;, having an appreciation for how subtle TAD and AAA can be; and recording and documenting a thorough history, physical examination, and risk factor profile, the emergency physician may reduce substantially the risk of missing a diagnosis and subsequently being sued. Emergency physicians cannot diagnose every case of acute aortic disease; what they can do is practice with a sound understanding of risk management principles and consider these diagnoses in all patients with chest, back, or abdominal pain.Ultimately, this strategy would provide protection for the patient and the physician.

Association of painless acute aortic dissection with increased mortality

OBJECTIVE

To evaluate the clinical characteristics and outcomes of patients with painless acute aortic dissection (AAD).

PATIENTS AND METHODS

For this study conducted from 1997 to 2001, we searched the International Registry of Acute Aortic Dissection to identify patients with painless AAD (group 1). Their clinical features and in-hospital events were compared with patients who had painful AAD (group 2).

RESULTS

Of the 977 patients in the database, 63 (6.4%) had painless AAD, and 914 (93.6%) had painful AAD. Patients in group 1 were older than those in group 2 (mean +/- SD age, 66.6 +/- 13.3 vs 61.9 +/- 14.1 years; P = .01). Type A dissection (involving the ascendIng aorta or the arch) was more frequent in group 1 (74.6% vs 60.9%; P = .03). Syncope (33.9% vs 11.7%; P < .001), congestive heart failure (19.7% vs 3.9%; P < .001), and stroke (11.3% vs 4.7%; P = .03) were more frequent presenting signs in group 1. Diabetes (10.2% vs 4.0%; P = .04), aortic aneurysm (29.5% vs 13.1%; P < .001), and prior cardiovascular surgery (48.1% vs 19.7%; P < .001) were also more common in group 1. In-hospital mortality was higher in group 1 (33.3% vs 23.2%; P = .05), especially due to type B dissection (limited to the descending aorta) (43.8% vs 10.4%; P < .001), and the prevalence of aortic rupture was higher among patients with type B dissection in group 1 (18.8% vs 5.9%; P = .04).

CONCLUSION

Patients with painless AAD had syncope, congestive heart failure, or stroke. Compared with patients who have painful AAD, patients who have painless AAD have higher mortality, especially when AAD is type B.

Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery

BACKGROUND

During aortic aneurysm surgery, cross-clamping can lead to inadequate blood supply to the spinal cord resulting in neurological deficit. Cerebrospinal fluid drainage (CSFD) may increase the perfusion pressure to the spinal cord and hence reduce the risk of ischaemic spinal cord injury.

OBJECTIVES

To determine the effect of CSFD during thoracic and thoracoabdominal aortic aneurysm (TAAA) surgery on the risk of developing spinal cord injury.

SEARCH STRATEGY

The reviewers searched the Cochrane Peripheral Vascular Diseases Group Specialised Trials Register (last searched October 2003), the Cochrane Central Register of Controlled Trials (CENTRAL) database (last searched Issue 4, 2003), MEDLINE and EMBASE, and reference lists of relevant articles. Recent conference proceedings were scanned.

SELECTION CRITERIA

Randomised trials involving CSFD during thoracic and TAAA surgery.

DATA COLLECTION AND ANALYSIS

Both reviewers assessed the quality of trials independently. One reviewer (SNK) extracted data and the other reviewer (GS) verified the data.

MAIN RESULTS

Three trials, with a total of 287 participants operated on for type I or II TAAA, were included. In the first trial of 98 patients, neurological deficits in the lower extremities occurred in 14 (30%) CSFD and 17 (33%) controls. The deficit was observed within 24 hours of the operation in 21 (68%), and from 3 to 22 days in 10 (32%). CSFD did not have a significant benefit in preventing ischaemic injury to the spinal cord. The second trial of 33 patients used a combination of CSFD and intrathecal papaverine. It showed a statistically significant reduction in the rate of postoperative neurological deficit (p = 0.039), compared to controls. Analysis was undertaken after only one third of the estimated sample size had entered the trial. In the third trial TAAA repair was performed on 145 patients. CSFD was initiated during the operation and continued for 48 hours after surgery. Paraplegia or paraparesis occurred in 9 of 74 patients (12.2%) in the control group versus 2 of 82 patients (2.7%) with CSFD (p = 0.03). Overall, CSFD resulted in an 80% reduction in the relative risk of postoperative deficits. Meta-analysis showed an odds ratio (OR) of 0.48 (0.25 to 0.92; confidence interval (CI) 95%). For CSFD trials only OR was 0.57 (0.28 to 1.17) and for intention-to-treat in CSFD only studies OR remained unchanged.

REVIEWER'S CONCLUSIONS

There are limited data supporting the role of CSFD in thoracic and thoracoabdominal aneurysm surgery for prevention of neurological injury. Further clinical and experimental studies are indicated.

Aortic emergencies

Prompt recognition of actual or impending aortic emergencies is essential to the effective practice of emergency medicine. Understanding the pathophysiologic principles and awareness of the potential subtleties in the clinical presentations of aortic dissection, aneurysm, and occlusive disease are prerequisites to this task. Knowledge of current diagnostic modalities is also important if these entities are to be identified rapidly and managed efficiently to maximize the potential for a good patient outcome. Awareness of the potential complications of these conditions and the necessary interventional and resuscitative measures that might be called for in the appropriate clinical setting are likewise essential requirements for the EP. Appropriate surgical consultation and mobilization of operative resources form the backbone of appropriate management in the patient who has an aortic emergency.

Clinical, diagnostic, and management perspectives of aortic dissection

The incidence of aortic dissection ranges from 5 to 30 cases per million people per year, depending on the prevalence of risk factors in the study population. Although the disease is uncommon, its outcome is frequently fatal, and many patients with aortic dissection die before presentation to the hospital or prior to diagnosis. While pain is the most common symptom of aortic dissection, more than one-third of patients may develop a myriad of symptoms secondary to the involvement of the organ systems. Physical findings may be absent or, if present, could be suggestive of a diverse range of other conditions. Keeping a high clinical index of suspicion is mandatory for the accurate and rapid diagnosis of aortic dissection. CT scanning, MRI, and transesophageal echocardiography are all fairly accurate modalities that are used to diagnose aortic dissection, but each is fraught with certain limitations. The choice of the diagnostic modality depends, to a great extent, on the availability and expertise at the given institution. The management of aortic dissection has consisted of aggressive antihypertensive treatment, when associated with systemic hypertension, and surgery. Recently, endovascular stent placement has been used for the treatment of aortic dissection in select patient populations, but the experience is limited. The technique could be an option for patients who are poor surgical candidates, or in whom the risk of complications is gravely high, especially so in the patients with distal dissections. The clinical, diagnostic, and management perspectives on aortic dissection and its variants, aortic intramural hematoma and atherosclerotic aortic ulcer, are reviewed.

Painless acute aortic dissection and rupture presenting as syncope

Acute aortic dissection is an emergency that may not only cause significant morbidity but often results in death. A timely diagnosis can prove difficult in the event of an atypical presentation. Classically, aortic dissection presents as sudden, severe chest, back, or abdominal pain that is characterized as ripping or tearing in nature. This article reports on a case of a completely painless acute dissection and rupture in a middle-aged man who presented with syncope. The diagnosis was made by a combination of clinical suspicion, emergent bedside echocardiography, and computed tomography scan. This patient underwent immediate surgery, and ultimately had a successful outcome.

Acute thoracoabdominal aortic dissection presenting as painless, transient paralysis of the lower extremities: a case report

Acute dissection of the aorta can be one of the most dramatic of cardiovascular emergencies. Its symptoms can occur abruptly and progress rapidly. Prompt recognition and appropriate intervention is crucial. However, not all aortic dissections present with classic symptoms of abrupt chest, back, or abdominal pain, and the diagnosis may be missed. A 63-year-old woman presented with transient loss of lower extremity motor and sensory function as the only symptom of an acute thoracoabdominal aortic dissection. Aortic dissection presenting as a transient neurologic syndrome is quite unusual. The sudden onset of weakness and parasthesia can result from the interruption of blood flow to the spinal cord. These symptoms of acute spinal cord ischemia, suggestive of a serious cardiovascular event, must be recognized and thoroughly investigated.

Painless aortic dissection presenting as high paraplegia: a case report

Acute aortic dissection is a catastrophic episode that usually presents as a sudden, painful, ripping sensation in the chest or back. Physical findings may include loss of pulses and aortic regurgitation. It is associated with neurologic sequelae in as many as one third of patients. Painless dissection occurs in 5% of patients. We report a case of painless aortic dissection, presenting as acute paraplegia. The patient was a 77-year-old woman who presented with paraplegia, with no chest or back pain. On examination, strength was 5/5 in both upper extremities and 0/5 in both lower extremities. Deep tendon reflexes were absent in her legs. She had no voluntary anal contraction. Sensation was absent from T6 through S5. Computed tomography of the chest revealed a type A dissecting aneurysm. The vascular supply to the spinal cord and the differential diagnosis for new onset paraplegia are discussed.

Spinal cord complications of thoracoabdominal aneurysm surgery

BACKGROUND

Although rare, paralysis secondary to spinal cord ischaemia after aortic aneurysm surgery is a devastating complication. Many papers have been published on this topic but without a clear consensus on the best way of minimizing the problem. Recent articles have included advanced pharmacological approaches and the literature has been reviewed in light of these.

METHODS

Relevant papers were identified by an extensive text word search of the Medline database and a review of quoted articles.

RESULTS

Spinal cord complications are commoner after the repair of Crawford type II aneurysms than less extensive aneurysms. The presence of dissection, rupture and prolonged clamp times are associated with an increased incidence. About a quarter of all cord problems develop over 24 h after surgery and this may be due to a reperfusion type injury, although the exact mechanisms are by no means clear.

CONCLUSION

A combination of rapid surgery, left heart bypass for the repair of more extensive aneurysms, free spinal drainage and the avoidance of postoperative hypoxia and hypotension help to minimize spinal cord ischaemia. No pharmacological agent has yet been shown conclusively to improve outcome in the clinical setting.

Anterior spinal artery infarction

Spinal cord ischemia, as represented by acute paraplegia, is rare in the absence of trauma. It is even more uncommon that an infarction of the spinal cord occurs in a patient with no predisposition to vascular disease. We report a case of anterior spinal artery syndrome resulting from an infarction of the anterior aspect of the spinal cord in an otherwise healthy 45-year-old woman.

Aortic pathology revealed by MRI in patients with clinical suspicion of spinal disease

In five patients with clinical suspicion of spinal disease, MRI of the spine revealed unexpected aortic pathology explaining the symptoms. No significant intraspinal pathology was found on MRI. However, in one patient with clinical suspicion of spinal stenosis, an aortic occlusion was detected on MR images of the spine. The lower extremity ischaemia, caused by the occlusion, was responsible for the symptoms. In another patient a paravertebral haematoma from a ruptured aortic aneurysm resulted in spinal nerve compression, thought before MRI to be caused by a spinal tumour. In three patients aortic aneurysm or dissection resulted in spinal cord ischaemia with symptoms mimicking those of compressive spinal disease. Thus, if MRI of the spine does not provide an explanation for the patient's symptoms, examination of the aorta is recommended.

Cervical anterior spinal artery syndrome associated with cardiopulmonary arrest

Nontraumatic spinal cord ischemia is uncommon, especially when the cervical cord is involved. We present an elderly man who sustained acute occlusion of the anterior spinal artery at a high cervical level. This was followed by a respiratory arrest due to the paralysis of the diaphragm and chest wall muscles. A review of the vascular supply to the cord and of nontraumatic ischemic myelopathy is provided.

Nontraumatic abdominal aortic thrombosis presenting with anterior spinal artery syndrome and pulmonary edema

A 51-year-old woman with a history of breast cancer developed pulmonary edema and lower extremity paraplegia with preservation of proprioception as the initial manifestation of abdominal aortic thrombosis. Back pain was present in the lumbar region radiating to buttocks and legs in a bilateral radicular pattern. Femoral pulses were initially palpable. Aortic angiography revealed complete abdominal aortic occlusion at L3 as well as total occlusion of the bilateral superficial femoral arteries and bilateral common iliac arteries. Transient occlusion of the anterior spinal artery due to aortic thrombosis may cause paraplegia and may also progress to renal failure, bowel infarction, and limb loss if left untreated. Abdominal aortic thrombosis needs to be considered in a patient who presents with an anterior spinal artery syndrome, which, if present, must be treated as rapidly as possible to preserve motor and sensory function.