Recurrent pulmonary embolism and pulmonary hypertension in chronic tetraplegia

The prevalence of pulmonary embolism in chronically paralyzed subjects: a review of available evidence

STUDY DESIGN

Qualitative systematic review.

OBJECTIVES

To examine the validity of the prevailing notion that pulmonary embolism (PE) is rare in the chronic spinal cord injury (SCI) population.

SETTING

USA.

METHODS

Review surveys of adult SCI subjects >2 months after injury in which PE has been looked for and its prevalence estimated.

RESULTS

A total of 16 surveys of chronic SCI subjects published between 1956 and 2009 offered data on PE prevalence. Two autopsy surveys, 178 subjects paralyzed >2 months, revealed no PE. Eleven surveys of the cause of death, 3193 subjects paralyzed 1-25 years, revealed PE in 2.1%. Two surveys of survivors of SCI, 5761 subjects paralyzed 1-25 years, revealed PE in 0.4%. Our survey of 112 subjects paralyzed 1-50 years before death, revealed PE in 21 (18.7%), based on autopsy, imaging, clinical and electrocardiographic evidence. In 7 (33%) of the 21 subjects with PE, pulmonary hypertension by transthoracic echocardiography was detected, indicating recurrent and/or unresolved PE.

CONCLUSION

PE is not infrequent in the chronic SCI subject; but its presentation may be subclinical; and its apparent recurrence may lead to pulmonary hypertension.

Orthostatic hypotension in the first month following acute spinal cord injury

STUDY DESIGN

Retrospective data analysis.

OBJECTIVES

To determine prevalence of orthostatic hypotension (OH) in patients with spinal cord injury (SCI) during the acute rehabilitation period.

SETTING

Quaternary care spinal unit, Vancouver General Hospital, British Columbia, Canada.

METHODS

Eighty-nine patients with acute SCI stratified by neurological level (cervical, 55 (62%); upper thoracic, 12 (13%); lower thoracic, 22 (25%)), and graded by American Spinal Injury Association standards. Non-invasive measurement of systolic and diastolic blood pressure and heart rate were made at baseline and 3 min following an orthostatic challenge test administered during the first month after SCI.

RESULTS

Patients with cervical or upper thoracic motor complete SCI more frequently experienced OH (P<0.01). OH persisted during the first month following SCI in 74% of cervical and only 20% of upper thoracic motor complete SCI patients.

CONCLUSION

Patients with cervical and upper thoracic motor complete SCI are more likely to experience persistent OH than those with lower level or motor incomplete SCI during the first month of rehabilitation.

Fibrinogen metabolism in patients with spinal cord injury

BACKGROUND/OBJECTIVE

Deep venous thrombosis and pulmonary thromboembolism are common within weeks of spinal cord injury (SCI) but clinically uncommon in the chronically paralyzed. Fibrinogen half-life (FHL) and fibrin uptake of the legs (FUT), as indicators of an active thrombotic process, have been used to test this clinical impression.

METHODS

Data from the use of autologous preparations of radioiodinated fibrinogen to determine FHL and FUT in 17 men paralyzed at cervical (6), thoracic (10), and lumbar levels (1), at ASIA grades A (15) and C (2) in 1974 to 1976 were reviewed. Group A consisted of 12 subjects 29 +/- 8 years of age and paralyzed 1 week to 5 months (median, 1 month). Group B consisted of 5 subjects 46 +/- 17 years of age and paralyzed 24 to 96 months (median, 36 months). Group B subjects were older and paralyzed longer than Group A. Group C consisted of 4 able-bodied control subjects enrolled at the same time for FHL studies, and these subjects were 34 to 38 years of age.

RESULTS

FHL was 61 +/- 14 hours for all SCI subjects and 95 +/- 23 hours for Group C (P = 0.001). Group A FHL was 59 +/- 16 hours, and FUT was positive in 8 of 12 subjects. Group B FHL was 66 +/- 7 hours, and FUT was positive in 3 of 4 subjects (1 FUT not done; P = 0.30 and 1.0, respectively).

CONCLUSIONS

Fibrinogen metabolism was abnormal in patients with acute SCI at high risk for pulmonary thromboembolism (PE) but continued to be abnormal beyond the high risk period for PE, possibly because of the greater age of the patients in the long-term paralysis group.