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Arasu T, Kumar R, Khajuria U, Komal T. Delayed Paraparesis: An Unusual Complication Following Coarctation of Aorta Repair. Ann Card Anaesth 2024; 27:82-84. [PMID: 38722130 PMCID: PMC10876145 DOI: 10.4103/aca.aca_98_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/13/2023] [Accepted: 08/30/2023] [Indexed: 05/12/2024] Open
Abstract
ABSTRACT Paraparesis following cardiac surgery is a manifestation of spinal cord injury (SCI). It can occur in any aortic surgery from the aneurysm to the coarctation of the aorta (CoA) where the cross-clamp of the aorta is applied. Though the incidence of paraplegia is low, its occurrence affects the morbidity and mortality of the patient. There are only sporadic case reports on the development of paraplegia following recurrent and technically challenging repair of CoA. However, the spontaneous development of paraplegia has also been reported in cases of unoperated CoA. The present report describes the case of delayed SCI in which paraparesis developed 5 days post a coarctation repair. The risk factors and strategies to protect the spinal cord during aortic surgeries are emphasized.
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Affiliation(s)
- Thanigai Arasu
- Department of Cardiac Anaesthesia, Sri Padmavati Children Heart Centre, Tirupati, AP, India
| | - Rupesh Kumar
- Department of Anesthesia and Intensive Care, PGIMER Chandigrah, India
| | - Udit Khajuria
- Department of Cardiac Surgery, Sri Padmavti Children Heart Center, Tirupati, AP, India
| | - T Komal
- Department of Cardiac Surgery, PGIMER, Chandigarh, India
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Gombert A, Simon F. Strategies to prevent and detect intraoperative spinal cord ischemia during complex aortic surgery: from drainages and biomarkers. Neural Regen Res 2021; 16:678-679. [PMID: 33063722 PMCID: PMC8067936 DOI: 10.4103/1673-5374.295328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Alexander Gombert
- Department of Vascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Florian Simon
- Department of Vascular and Endovascular Surgery, Heinrich-Heine-University of Düsseldorf, Düsseldorf, Germany
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Panthee N, Ono M, Yamamoto T, Ikemura M, Tanaka T, Itoda Y, Suzuki H. Evaluation of spinal cord protective threshold of serum memantine, an NMDA receptor antagonist, in a rabbit model of paraplegia. Indian J Thorac Cardiovasc Surg 2020; 36:598-607. [PMID: 33100621 DOI: 10.1007/s12055-020-01026-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/21/2020] [Accepted: 07/28/2020] [Indexed: 11/27/2022] Open
Abstract
Purpose To evaluate the threshold of serum memantine for prevention of spinal cord injury (SCI) in a rabbit paraplegic model. Methods Forty-two New Zealand white rabbits were divided into 7 groups. Preoperatively, oral memantine was given starting from 60 mg OD for 7 days in the initial group, then reducing the dose and/or duration to 60 mg OD for 5 days, 30 mg OD for 5 days, 30 mg OD for 3 days, 15 mg OD for 3 days, 30 mg single dose, and 60 mg single dose, in subsequent 6 groups. A paraplegic model was created by clamping both infrarenal aorta and inferior vena cava (IVC) for 45 min. Motor evoked potentials (MEPs), modified Tarlov score (0-5), serum memantine concentration, and histopathology of the spinal cord were evaluated. Results Half of all rabbits (21/42) showed spinal protection. Receiver operating characteristic (ROC) curve analysis showed serum level of 4.5 ng/ml as a cutoff value for spinal protection (sensitivity 86%, specificity 62%, area under the curve (AUC) 0.785, P = .002). Sixteen rabbits had serum level ≥ 4.5 ng/ml (group A), with 26 rabbits having < 4.5 ng/ml (group B). Further comparison was done between groups A and B. The mean modified Tarlov score at 6, 24, 48, and 72 h was 4.5 ± 0.9 and 2.4 ± 1.6, in groups A and B, respectively (P < .001). The modified Tarlov score showed positive correlation with serum memantine level (Spearman's rho = 0.618, P = .01). Results of MEP and histopathology were significantly better for group A. Conclusions We showed that memantine is protective against SCI at serum levels ≥ 4.5 ng/ml in a rabbit model; thus, it can be a potential adjunct for spinal protection during thoracic/thoracoabdominal aortic surgeries.
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Affiliation(s)
- Nirmal Panthee
- Department of Cardiac Surgery, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Takehito Yamamoto
- Department of Pharmacy, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Masako Ikemura
- Department of Neuropathology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Tsuruhito Tanaka
- Department of Cardiac Surgery, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Yoshifumi Itoda
- Department of Cardiac Surgery, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Hiroshi Suzuki
- Department of Pharmacy, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
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Impact of shaggy aorta on outcomes of open thoracoabdominal aortic aneurysm repair. J Thorac Cardiovasc Surg 2020; 160:889-897.e1. [DOI: 10.1016/j.jtcvs.2019.07.112] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 07/21/2019] [Accepted: 07/26/2019] [Indexed: 01/05/2023]
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Pasqualucci A, Al-Sibaie A, Vaidyan KPT, Paladini A, Nadhari MY, Gori F, Greiss HF, Properzi M, Al Ani OSM, Godwin A, Syedkazmi AH, Elhanf OA, Varrassi G. Epidural Corticosteroids, Lumbar Spinal Drainage, and Selective Hemodynamic Control for the Prevention of Spinal Cord Ischemia in Thoracoabdominal Endovascular Aortic Repair: A New Clinical Protocol. Adv Ther 2020; 37:272-287. [PMID: 31721112 DOI: 10.1007/s12325-019-01146-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION In patients undergoing thoracoabdominal aorta repair, spinal cord ischemia (SCI) remains one of the most common and important complications resulting in transient paraparesis through to permanent flaccid paraplegia. In this manuscript, after a brief introduction to spinal cord ischemia complication and its prevention in thoracoabdominal endovascular aortic repair (TEVAR), we propose a new clinical protocol potentially able to prevent such complication. METHODS The proposed protocol suggests the use of high dosages of corticosteroids by epidural route, along with drainage of cerebrospinal fluid and controlled vascular hypertension, to reduce the incidence of SCI in TEVAR. Moreover, we paid particular attention to the control of the hemodynamic parameters to obtain adequate peripheral tissue perfusion (oxygen delivery), including in the spinal cord. RESULTS We applied this new protocol in 50 consecutive patients treated with TEVAR for thoracoabdominal aortic aneurysms (TAAs); 47 patients completed the procedure: 27 patients Crawford type I and 20 Crawford type II. Three patients died during surgery because of untreatable aneurysm rupture. The results show that in all patients there were no cases of SCI, after 5 days from TEVAR. DISCUSSION To the best of our knowledge, there are no clinical studies on the use of epidural corticosteroids in patients undergoing treatment of aortic syndrome (both in "open surgery" and endovascular aortic repair). This initial study on 50 consecutive patients has shown that the clinical protocol used could be of great interest to prevent one of the worse complications of TEVAR. Its limitations are the low number of patients studied till now, and the non-randomized protocol adopted. Further studies would be necessary. CONCLUSION Our experience and the results obtained with this new perioperative protocol with epidural corticosteroid and accurate hemodynamic control have been encouraging and it seems a valid proposal to be explored in future by well-structured prospective, randomized protocols.
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Affiliation(s)
- Alberto Pasqualucci
- Department of Surgical and Biomedical Science, University Hospital of Perugia, 06100, Perugia, Italy
- Rashid Hospital, Trauma and Emergency Center (Dubai Health Authority), Dubai, UAE
| | - Ayman Al-Sibaie
- Rashid Hospital, Trauma and Emergency Center (Dubai Health Authority), Dubai, UAE
| | | | | | | | - Fabio Gori
- Department of Surgical and Biomedical Science, University Hospital of Perugia, 06100, Perugia, Italy
| | - Hany Fawzy Greiss
- Rashid Hospital, Trauma and Emergency Center (Dubai Health Authority), Dubai, UAE
| | - Marina Properzi
- Department of Surgical and Biomedical Science, University Hospital of Perugia, 06100, Perugia, Italy
| | | | - Aruna Godwin
- Rashid Hospital, Trauma and Emergency Center (Dubai Health Authority), Dubai, UAE
| | | | - Osama Ahmed Elhanf
- Rashid Hospital, Trauma and Emergency Center (Dubai Health Authority), Dubai, UAE
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Lewis ER, Geisbüsch S, Chang YJ, Costa V, Husain S, Soteropoulos P, Griepp RB, Di Luozzo G. Paraspinous muscle gene expression profiling following simulated staged endovascular repair of thoracoabdominal aortic aneurysm: exploring potential therapeutic pathways. Eur J Cardiothorac Surg 2019; 57:30-38. [DOI: 10.1093/ejcts/ezz113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 03/11/2019] [Accepted: 03/13/2019] [Indexed: 02/01/2023] Open
Abstract
Abstract
OBJECTIVES
Thoracic endovascular techniques for aneurysm repair offer less invasive alternatives to open strategies. Both approaches, however, are associated with the risk for neurological complications. Despite adjuncts to maintain spinal cord perfusion, ischaemia and paraplegia continue to occur during thoracoabdominal aortic aneurysm (TAAA) repair. Staging of such extensive procedures has been proven to decrease the risk for spinal cord injury. Archived biopsy specimens may offer insight into the molecular signature of the reorganization and expansion of the spinal collateral network during staged endovascular interventions in the setting of TAAA.
METHODS
Biological replicates of total RNA were isolated from existing paraspinous muscle samples from 22 Yorkshire pigs randomized to 1 of 3 simulated TAAA repair strategies as part of a previous study employing coil embolization of spinal segmental arteries within the thoracic and lumbar spine. Gene expression profiling was performed using the Affymetrix GeneChip Porcine array.
RESULTS
Microarray analysis identified 649 differentially expressed porcine genes (≥1.3-fold change, P ≤ 0.05) when comparing paralysed and non-paralysed subjects. Of these, 355 were available for further analysis. When mapped to the human genome, 169 Homo sapiens orthologues were identified. Integrated interpretation of gene expression profiles indicated the significant regulation of transcriptional regulators (such as nuclear factor кB), cytokine (including CXCL12) elements contributing to hypoxia signalling in the cardiovascular system (vascular endothelial growth factor and UBE2) and cytoskeletal elements (like dystrophin (DMD) and matrix metallopeptidase (MMP)).
CONCLUSIONS
This study demonstrates the ability of microarray-based platforms to detect the differential expression of genes in paraspinous muscle during staged TAAA repair. Pathway enrichment analysis detected subcellular actors accompanying the neuroprotective effects of staged endovascular coiling. These observations provide new insight into the potential prognostic and therapeutic value of gene expression profiling in monitoring and modulating the arteriolar remodelling in the collateral network.
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Affiliation(s)
- Erin R Lewis
- Department of Surgery, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Sarah Geisbüsch
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yun-Juan Chang
- Office of Advanced Research Computing, Rutgers University, Newark, NJ, USA
| | - Victor Costa
- Department of Surgery, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Seema Husain
- Genomics Center, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | | | - Randall B Griepp
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gabriele Di Luozzo
- Department of Surgery, Rutgers-New Jersey Medical School, Newark, NJ, USA
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Ghincea CV, Ikeno Y, Aftab M, Reece TB. Spinal Cord Protection for Thoracic Aortic Surgery: Bench to Bedside. Semin Thorac Cardiovasc Surg 2019; 31:713-720. [DOI: 10.1053/j.semtcvs.2019.02.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 02/22/2019] [Indexed: 11/11/2022]
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Kang SK, Kang MW, Rhee YJ, Kim CS, Jeon BH, Han SJ, Cho HJ, Na MH, Yu JH. In Vivo Neuroprotective Effect of Histidine-Tryptophan-Ketoglutarate Solution in an Ischemia/Reperfusion Spinal Cord Injury Animal Model. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:232-41. [PMID: 27525231 PMCID: PMC4981224 DOI: 10.5090/kjtcs.2016.49.4.232] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/29/2015] [Accepted: 12/01/2015] [Indexed: 11/25/2022]
Abstract
Background Paraplegia is a devastating complication following operations on the thoracoabdominal aorta. We investigated whether histidine-tryptophan-ketoglutarate (HTK) solution could reduce the extent of ischemia/reperfusion (IR) spinal cord injuries in a rat model using a direct delivery method. Methods Twenty-four Sprague-Dawley male rats were randomly divided into four groups. The sham group (n=6) underwent a sham operation, the IR group (n=6) underwent only an aortic occlusion, the saline infusion group (saline group, n=6) underwent an aortic occlusion and direct infusion of cold saline into the occluded aortic segment, and the HTK infusion group (HTK group, n=6) underwent an aortic occlusion and direct infusion of cold HTK solution into the occluded aortic segment. An IR spinal cord injury was induced by transabdominal clamping of the aorta distally to the left renal artery and proximally to the aortic bifurcation for 60 minutes. A neurological evaluation of locomotor function was performed using the modified Tarlov score after 48 hours of reperfusion. The spinal cord was harvested for histopathological and immunohistochemical examinations. Results The spinal cord IR model using direct drug delivery in rats was highly reproducible. The Tarlov score was 4.0 in the sham group, 1.17±0.75 in the IR group, 1.33±1.03 in the saline group, and 2.67±0.81 in the HTK group (p=0.04). The histopathological analysis of the HTK group showed reduced neuronal cell death. Conclusion Direct infusion of cold HTK solution into the occluded aortic segment may reduce the extent of spinal cord injuries in an IR model in rats.
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Affiliation(s)
- Shin Kwang Kang
- Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine
| | - Min-Woong Kang
- Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine
| | - Youn Ju Rhee
- Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine
| | - Cuk-Seong Kim
- Department of Physiology, Chungnam National University School of Medicine
| | - Byeong Hwa Jeon
- Department of Physiology, Chungnam National University School of Medicine
| | - Sung Joon Han
- Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine
| | - Hyun Jin Cho
- Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine
| | - Myung Hoon Na
- Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine
| | - Jae-Hyeon Yu
- Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine
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Panthee N, Ono M, Morota T, Tanaka T, Itoda Y, Ikemura M, Yamamoto T, Suzuki H, Saito A, Motomura N. Paraplegia prevention by oral pretreatment with memantine in a rabbit model. J Thorac Cardiovasc Surg 2014; 148:1732-8. [PMID: 24908351 DOI: 10.1016/j.jtcvs.2014.04.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 04/22/2014] [Accepted: 04/24/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the role of memantine (N-methyl-d-aspartate receptor antagonist) pretreatment for the prevention of spinal cord ischemia after infrarenal aortic clamping in a rabbit model. METHODS Thirty New Zealand White rabbits were divided into 5 different groups of 6 rabbits. Groups 60-7 and 60-5 received oral memantine 60 mg once a day for 7 and 5 days, respectively, and groups 30-5 and 30-3 received oral memantine 30 mg once a day for 5 and 3 days, respectively, all before surgery. Group C (control) received normal feeds without memantine. A paraplegic model was created by clamping both the aorta and the inferior vena cava infrarenally and just proximal to their bifurcations for 45 minutes. The modified Tarlov score, motor evoked potential (MEP), serum memantine concentration, and histopathology of the spinal cord were evaluated. RESULTS The mean modified Tarlov scores were 4.2±1.3, 4.3±1.0, 4.2±1.3, 4.3±1.2, and 0.8±1.6 in groups 60-7, 60-5, 30-5, 30-3, and C, respectively at 6, 24, 48, and 72 hours (P<.009 for individual groups vs control). Percentage amplitude loss of MEP by the end of surgery was 29.5%±46.3%, 11.9%±28.0%, 30.0%±46.8%, 16.7%±40.8%, and 81.8%±40.3% for the 5 groups, respectively (P=.049). After declamping, MEP reappeared in 83%, 100%, 83%, 83%, and 33% of cases in the 5 groups, respectively (P=.073). The serum memantine level was similar in the 4 memantine groups. Spinal cords were normal in most of the rabbits in groups 60-7, 60-5, 30-5, and 30-3, but severely ischemic in most of the rabbits in group C (P=.041). CONCLUSIONS Oral memantine pretreatment is protective against spinal cord ischemia, and can be an additional strategy for the prevention of paraplegia during thoracoabdominal aortic surgeries.
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Affiliation(s)
- Nirmal Panthee
- Department of Cardiac Surgery, University of Tokyo, Hongo Bunkyo-ku, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, University of Tokyo, Hongo Bunkyo-ku, Tokyo, Japan.
| | - Tetsuro Morota
- Department of Cardiac Surgery, University of Tokyo, Hongo Bunkyo-ku, Tokyo, Japan
| | - Tsuruhito Tanaka
- Department of Cardiac Surgery, University of Tokyo, Hongo Bunkyo-ku, Tokyo, Japan
| | - Yoshifumi Itoda
- Department of Cardiac Surgery, University of Tokyo, Hongo Bunkyo-ku, Tokyo, Japan
| | - Masako Ikemura
- Department of Neuropathology, University of Tokyo, Hongo Bunkyo-ku, Tokyo, Japan
| | - Takehito Yamamoto
- Department of Pharmacy, University of Tokyo, Hongo Bunkyo-ku, Tokyo, Japan
| | - Hiroshi Suzuki
- Department of Pharmacy, University of Tokyo, Hongo Bunkyo-ku, Tokyo, Japan
| | - Aya Saito
- Department of Cardiac Surgery, University of Tokyo, Hongo Bunkyo-ku, Tokyo, Japan
| | - Noboru Motomura
- Department of Cardiac Surgery, University of Tokyo, Hongo Bunkyo-ku, Tokyo, Japan
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Bell MT, Puskas F, Agoston VA, Cleveland JC, Freeman KA, Gamboni F, Herson PS, Meng X, Smith PD, Weyant MJ, Fullerton DA, Reece TB. Toll-Like Receptor 4–Dependent Microglial Activation Mediates Spinal Cord Ischemia–Reperfusion Injury. Circulation 2013; 128:S152-6. [DOI: 10.1161/circulationaha.112.000024] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background—
Paraplegia continues to complicate thoracoabdominal aortic interventions. The elusive mechanism of spinal cord ischemia–reperfusion injury has delayed the development of pharmacological adjuncts. Microglia, the resident macrophages of the central nervous system, can have pathological responses after a variety of insults. This can occur through toll-like receptor 4 (TLR-4) in stroke models. We hypothesize that spinal cord ischemia–reperfusion injury after aortic occlusion results from TLR-4–mediated microglial activation in mice.
Methods and Results—
TLR-4 mutant and wild-type mice underwent aortic occlusion for 5 minutes, followed by 60 hours of reperfusion when spinal cords were removed for analysis. Spinal cord cytokine production and microglial activation were assessed at 6 and 36 hours after surgery. Isolated microglia from mutant and wild-type mice were subjected to oxygen and glucose deprivation for 24 hours, after which the expression of TLR-4 and proinflammatory cytokines was analyzed. Mice without functional TLR-4 demonstrated decreased microglial activation and cytokine production and had preserved functional outcomes and neuronal viability after thoracic aortic occlusion. After oxygen and glucose deprivation, wild-type microglia had increased TLR-4 expression and production of proinflammatory cytokines.
Conclusions—
The absence of functional TLR-4 attenuated neuronal injury and microglial activation after thoracic aortic occlusion in mice. Furthermore, microglial upregulation of TLR-4 occurred after oxygen and glucose deprivation, and the absence of functional TLR-4 significantly attenuated the production of proinflammatory cytokines. In conclusion, TLR-4–mediated microglia activation in the spinal cord after aortic occlusion is critical in the mechanism of paraplegia after aortic cross-clamping and may provide targets for pharmacological intervention.
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Affiliation(s)
- Marshall T. Bell
- From the Departments of Cardiothoracic Surgery (M.T.B., V.A.A., J.C.C., K.A.F., F.G., X.M., P.D.S., M.J.W., D.A.F., T.B.R.) and Anesthesiology (F.P., P.S.H.), University of Colorado, Denver, CO
| | - Ferenc Puskas
- From the Departments of Cardiothoracic Surgery (M.T.B., V.A.A., J.C.C., K.A.F., F.G., X.M., P.D.S., M.J.W., D.A.F., T.B.R.) and Anesthesiology (F.P., P.S.H.), University of Colorado, Denver, CO
| | - Viktor A. Agoston
- From the Departments of Cardiothoracic Surgery (M.T.B., V.A.A., J.C.C., K.A.F., F.G., X.M., P.D.S., M.J.W., D.A.F., T.B.R.) and Anesthesiology (F.P., P.S.H.), University of Colorado, Denver, CO
| | - Joseph C. Cleveland
- From the Departments of Cardiothoracic Surgery (M.T.B., V.A.A., J.C.C., K.A.F., F.G., X.M., P.D.S., M.J.W., D.A.F., T.B.R.) and Anesthesiology (F.P., P.S.H.), University of Colorado, Denver, CO
| | - Kirsten A. Freeman
- From the Departments of Cardiothoracic Surgery (M.T.B., V.A.A., J.C.C., K.A.F., F.G., X.M., P.D.S., M.J.W., D.A.F., T.B.R.) and Anesthesiology (F.P., P.S.H.), University of Colorado, Denver, CO
| | - Fabia Gamboni
- From the Departments of Cardiothoracic Surgery (M.T.B., V.A.A., J.C.C., K.A.F., F.G., X.M., P.D.S., M.J.W., D.A.F., T.B.R.) and Anesthesiology (F.P., P.S.H.), University of Colorado, Denver, CO
| | - Paco S. Herson
- From the Departments of Cardiothoracic Surgery (M.T.B., V.A.A., J.C.C., K.A.F., F.G., X.M., P.D.S., M.J.W., D.A.F., T.B.R.) and Anesthesiology (F.P., P.S.H.), University of Colorado, Denver, CO
| | - Xianzhong Meng
- From the Departments of Cardiothoracic Surgery (M.T.B., V.A.A., J.C.C., K.A.F., F.G., X.M., P.D.S., M.J.W., D.A.F., T.B.R.) and Anesthesiology (F.P., P.S.H.), University of Colorado, Denver, CO
| | - Phillip D. Smith
- From the Departments of Cardiothoracic Surgery (M.T.B., V.A.A., J.C.C., K.A.F., F.G., X.M., P.D.S., M.J.W., D.A.F., T.B.R.) and Anesthesiology (F.P., P.S.H.), University of Colorado, Denver, CO
| | - Michael J. Weyant
- From the Departments of Cardiothoracic Surgery (M.T.B., V.A.A., J.C.C., K.A.F., F.G., X.M., P.D.S., M.J.W., D.A.F., T.B.R.) and Anesthesiology (F.P., P.S.H.), University of Colorado, Denver, CO
| | - David A. Fullerton
- From the Departments of Cardiothoracic Surgery (M.T.B., V.A.A., J.C.C., K.A.F., F.G., X.M., P.D.S., M.J.W., D.A.F., T.B.R.) and Anesthesiology (F.P., P.S.H.), University of Colorado, Denver, CO
| | - T. Brett Reece
- From the Departments of Cardiothoracic Surgery (M.T.B., V.A.A., J.C.C., K.A.F., F.G., X.M., P.D.S., M.J.W., D.A.F., T.B.R.) and Anesthesiology (F.P., P.S.H.), University of Colorado, Denver, CO
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Bell MT, Puskas F, Smith PD, Agoston VA, Fullerton DA, Meng X, Weyant MJ, Reece TB. Attenuation of spinal cord ischemia-reperfusion injury by specific α-2a receptor activation with dexmedetomidine. J Vasc Surg 2012; 56:1398-402. [PMID: 22832266 DOI: 10.1016/j.jvs.2012.04.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 03/29/2012] [Accepted: 04/05/2012] [Indexed: 01/12/2023]
Abstract
BACKGROUND Despite surgical adjuncts, paralysis remains a devastating complication after thoracoabdominal aortic interventions. Dexmedetomidine, a selective α-2a agonist commonly used for sedation in the critical care setting, has been shown to have protective effects against ischemia-reperfusion injuries in multiple organ systems. We hypothesized that treatment with dexmedetomidine would attenuate spinal cord ischemia-reperfusion injury via α-2a receptor activation. METHODS Adult C57BL/6 mice underwent sternotomy, followed by occlusion of the aortic arch for 4 minutes. Eight experimental mice received pretreatment with intraperitoneal dexmedetomidine (25 μg/kg) and at 12-hour intervals after reperfusion. Eight control mice received an equivalent amount of 0.9% normal saline. Five mice underwent the same procedure with dexmedetomidine (25 μg/kg) and atipamezole (250 μg/kg), an α-2a receptor antagonist. Functional analysis of the mice was obtained at 12-hour intervals and scored using the Basso Mouse Scale for Locomotion until 60 hours. All mice were euthanized at 60 hours. Their spinal cords were removed en bloc and were stained with hematoxylin and eosin to assess cytoarchitecture and neuronal viability. RESULTS Mice treated with the α-2a agonist demonstrated preserved motor function compared with ischemic controls and with mice treated with the α-2a antagonist in addition to the agonist. Functional differences in the dexmedetomidine group were statistically significant from 24 hours through the remainder of the experiment (P < .05). In addition, the treated mice had preserved cytoarchitecture, decreased vacuolization, and improved neuronal viability compared with ischemic control mice and mice concurrently treated with atipamezole, the dexmedetomidine α-2a antagonist. CONCLUSIONS Treatment of mice with the α-2a agonist dexmedetomidine preserves motor function and neuronal viability after aortic cross-clamping. In addition, mice exhibited almost complete reversal of the protective effect with the administration of the α-2a receptor antagonist atipamezole. Dexmedetomidine appears to attenuate spinal cord ischemia-reperfusion injury via α-2a receptor-mediated agonism. CLINICAL RELEVANCE There remains a significant risk of paraplegia after thoracoabdominal aortic interventions. This complication is devastating to the patient and the health care system. Pharmacologic adjuncts to further decrease this complication have been studied; however, few viable options exist. The α-2a agonists have been shown to improve outcomes after strokes but have not been studied in spinal cord ischemia. We show that dexmedetomidine, a commonly used α-2a agonist in the operating room, can preserve neurologic function in mice after aortic cross-clamping. Although the protective mechanism of dexmedetomidine remains unknown, it might prove to be beneficial in reducing the incidence of paraplegia after aortic interventions.
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Affiliation(s)
- Marshall T Bell
- Department of Cardiothoracic Surgery, University of Colorado, Aurora, Colo, USA.
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Ullery BW, Wang GJ, Low D, Cheung AT. Neurological complications of thoracic endovascular aortic repair. Semin Cardiothorac Vasc Anesth 2011; 15:123-40. [PMID: 22025398 DOI: 10.1177/1089253211424224] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) has decreased the morbidity and mortality associated with open surgical repair of descending thoracic aortic diseases, but important complications unique to the procedure remain. Spinal cord ischemia and infarction is a recognized complication caused by endovascular coverage or injury to spinal cord collateral vessels. Stroke is a consequence of thromboembolism or coverage of aortic arch branch vessels with insufficient collateral circulation. Understanding the risk factors and the pathophysiology of neurological complications of TEVAR are important for the successful anesthetic and surgical management and treatment of patients undergoing endovascular procedures involving the thoracic aorta.
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Affiliation(s)
- Brant W Ullery
- Department of Anesthesiology and Critical Care, University of Pennsylvania, 3400 Spruce Street, Dulles 680, Philadelphia, PA 19104-4283, USA
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13
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Current strategies for spinal cord protection during thoracic and thoracoabdominal aortic aneurysm repair. Gen Thorac Cardiovasc Surg 2011; 59:155-63. [DOI: 10.1007/s11748-010-0705-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 08/30/2010] [Indexed: 11/26/2022]
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Carmona P, Mateo E, Otero M, Marqués JI, Peña JJ, Llagunes J, Aguar F, De Andrés J. [Spinal cord protection during open and endovascular surgery in thoracic and thoracoabdominal aorta diseases]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2011; 58:110-118. [PMID: 21427827 DOI: 10.1016/s0034-9356(11)70009-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
In recent decades great advances have been made in surgical procedures for treating thoracic and thoracoabdominal aorta defects. Associated mortality and morbidity rates have dropped considerably, mainly in major reference centers, but nonetheless continue to be significant. The need for new strategies to reduce mortality and morbidity has made endovascular approaches an attractive alternative for high-risk surgical patients. The most feared complications of these procedures include paraparesis and paraplegia, which have devastating consequences on patients' quality of life. We provide an updated review of the pathophysiology of spinal cord ischemia in open and endovascular surgery, as well as perioperative measures designed to protect the spinal cord in both types of procedure.
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Affiliation(s)
- P Carmona
- Consorcio Hospital General Universitario de Valencia.
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Fansa I, Altug ME, Melek I, Ucar E, Kontas T, Akcora B, Atik E, Duman T. The Neuroprotective and Anti-inflammatory Effects of Diltiazem in Spinal Cord Ischaemia–Reperfusion Injury. J Int Med Res 2009; 37:520-33. [DOI: 10.1177/147323000903700228] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The protective effects of diltiazem were examined in a rabbit model of spinal cord ischaemia–reperfusion induced by infrarenal aortic occlusion for 30 min. In the diltiazem group ( n = 6), an intravenous infusion (2 μg/kg per min) was started 10 min before ischaemia induction; normal saline solution was infused in the control group ( n = 6). Neurological function was assessed using modified Tarlov criteria 24 h after surgery. Plasma samples were analysed for interleukin (IL)-6 and IL-10. Spinal tissue was analysed for malondialdehyde, nitric oxide and reduced glutathione activities. Tarlov scores of the diltiazem-treated rabbits indicated significantly improved hind-limb motor function compared with the control group. The diltiazem group also had better quantitative and qualitative histopathological findings. Diltiazem infusion significantly reduced IL-6 levels 3 and 24 h after reperfusion compared with the control group. The mean IL-10 level in the diltiazem group was significantly higher than in the control group 24 h after reperfusion. It is concluded that diltiazem has cytoprotective and anti-inflammatory properties, leading to reduced spinal cord injury.
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Affiliation(s)
- I Fansa
- Department of Cardiovascular Surgery, Faculty of Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey
| | - ME Altug
- Department of Surgery, Faculty of Veterinary Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey
| | - I Melek
- Department of Neurology, Faculty of Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey
| | - E Ucar
- Department of Internal Medicine, Faculty of Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey
| | - T Kontas
- Department of Biochemistry, Faculty of Veterinary Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey
| | - B Akcora
- Department of Paediatric Surgery, Faculty of Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey; and
| | - E Atik
- Department of Pathology, Faculty of Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey
| | - T Duman
- Department of Neurology, Faculty of Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey
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Reece TB, Tribble CG, Okonkwo DO, Davis JD, Maxey TS, Gazoni LM, Linden J, Kron IL, Kern JA. Early adenosine receptor activation ameliorates spinal cord reperfusion injury. J Cardiovasc Med (Hagerstown) 2008; 9:363-7. [PMID: 18334890 DOI: 10.2459/jcm.0b013e3282eee836] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Adenosine receptor activation at reperfusion has been shown to ameliorate ischemia-reperfusion injury of the spinal cord, but the effects of therapy given in response to ischemic injury are unknown. We hypothesized that adenosine receptor activation with ATL-146e would produce similar protection from ischemic spinal cord injury, whether given at reperfusion or in a delayed fashion. METHODS Twenty-two New Zealand white rabbits were divided into three groups. All three groups, including the ischemia-reperfusion group (IR, n = 8), underwent 45 min of infrarenal aortic occlusion. The early treatment group (early, n = 8) received 0.06 mug/kg/min of ATL-146e for 3 h beginning 10 min prior to reperfusion. The delayed treatment group (delayed, n = 6) received ATL-146e starting 1 h after reperfusion. After 48 h, hind limb function was graded using the Tarlov score. Finally, lumbar spinal cord neuronal cytoarchitecture was evaluated. RESULTS Hemodynamic parameters were similar among the groups. Hind limb function at 48 h was significantly better in the early group (3.5 +/- 1.0) compared to the IR group (0.625 +/- 0.5, P < or = 0.01). There was a trend towards better hind limb function in the early group compared to the delayed group (2.4 +/- 1.1, P = 0.08). Hind limb function was similar between delayed and IR groups. Hematoxylin-eosin spinal cord sections demonstrated preservation of viable motor neurons in the early group compared to the delayed and IR groups. CONCLUSIONS Early therapy with ATL-146e provided better protection in this study; therefore, therapy should not be delayed until there is evidence of ischemic neurological deficit. This study suggests that adenosine receptor activation is most effective as a preventive strategy at reperfusion for optimal protection in spinal cord ischemia-reperfusion injury.
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Affiliation(s)
- T Brett Reece
- Department of Surgery, University of Virginia, Charlottesville, Virginia, USA.
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Kim KO, Choe G, Chung SH, Kim CS. Delayed pharmacological pre-conditioning effect of mitochondrial ATP-sensitive potassium channel opener on neurologic injury in a rabbit model of spinal cord ischemia. Acta Anaesthesiol Scand 2008; 52:236-42. [PMID: 18005376 DOI: 10.1111/j.1399-6576.2007.01534.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Diazoxide, pharmacological openers of mitochondrial ATP-sensitive potassium channels have been shown to induce early pre-conditioning in the spinal cord. Here, the authors investigated whether diazoxide also induce delayed pre-conditioning and thereby reduce neurologic complications using a rabbit model of spinal cord ischemia. METHODS Infrarenal blood flow was interrupted for 20 min in 21 rabbits. Non-treated control animals received no pre-treatment. Diazoxide (5 mg/kg) were given 48 h before 20 min ischemia in the 48-h DZ group, whereas 15-min DZ group received diazoxide (5 mg/kg) 15 min before 20-min ischemia. Neurological functions were evaluated using Johnson scores for 3 days after reperfusion, after which, spinal cords were procured for hematoxylin and eosin staining for cell counting. RESULTS Johnson scores revealed a marked improvement in both the diazoxide-treated groups vs. the non-treated control group at 3, 24, 48, and 72 h after reperfusion (P<0.01). The histologic changes were proportional to the Johnson scores, with better preservation of motor neuron numbers in the animals of the 48-h DZ and 15-min DZ group relative to the non-treated controls (81+/-12, 90+/-10, 50+/-23 motor neurons, respectively, P<0.01). No difference was found between the 48-h DZ group and 15-min DZ group with respect to the Johnson scores or neuron numbers. CONCLUSIONS The study demonstrates that pre-treatment with diazoxide 48 h before ischemia, induce delayed pharmacological pre-conditioning, thereby significantly improving clinical neurologic scores and histologic findings in this animal model.
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Affiliation(s)
- K O Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea.
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Reece TB, Kron IL, Okonkwo DO, Laurent JJ, Tache-Leon C, Maxey TS, Ellman PI, Linden J, Tribble CG, Kern JA. Functional and cytoarchitectural spinal cord protection by ATL-146e after ischemia/reperfusion is mediated by adenosine receptor agonism. J Vasc Surg 2006; 44:392-7. [PMID: 16890874 DOI: 10.1016/j.jvs.2006.04.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Accepted: 04/14/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND ATL-146e protects the spinal cord from ischemia/reperfusion injury, presumably via adenosine A(2A) receptor activation, but this relationship remains unproven. We hypothesized that spinal cord functional and cytoarchitectural preservation from ATL-146e would be lost with simultaneous administration of the specific adenosine A(2A) antagonist ZM241385 (ZM), thus proving that adenosine A(2A) receptor activation is responsible for the protective effects of this compound. METHODS New Zealand White rabbits underwent 45 minutes of infrarenal aortic cross-clamping. Groups (n = 10) included sham, ischemia, ischemia plus ATL-146e (ATL-146E), ischemia plus ZM, or ischemia with both compounds (agonist-antagonist). Tarlov scores were recorded every 12 hours. After 48 hours, the spinal cord was fixed for histology and microtubule-associated protein 2 immunohistochemistry. RESULTS Tarlov scores at 48 hours were significantly better in the sham and ATL-146E groups (5.0 and 3.9, respectively) compared with the other three groups (all < or =1.3; P < .001). On hematoxylin and eosin, neuronal viability was higher in the sham, ATL-146E, and agonist-antagonist groups compared with the control and ZM groups (P < .05). Microtubule-associated protein 2 expression was preserved in the sham and ATL-146E groups but was lost in the ATL + ZM, ZM241385, and control groups. CONCLUSIONS ATL-146e preserves the spinal cord in terms of both cytoarchitecture and function after reperfusion of the ischemic spinal cord, but this preservation is not completely blocked by competitive adenosine A(2A) receptor antagonism. Although ATL-146e does seem to partially function through activation of the adenosine A(2A) receptor, the neuroprotective mechanism may not be limited to this particular receptor.
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Affiliation(s)
- T Brett Reece
- Department of Surgery, University of Virginia, Charlottesville, VA 22908, USA.
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Reece TB, Okonkwo DO, Ellman PI, Maxey TS, Tache-Leon C, Warren PS, Laurent JJ, Linden J, Kron IL, Tribble CG, Kern JA. Comparison of systemic and retrograde delivery of adenosine A2A agonist for attenuation of spinal cord injury after thoracic aortic cross-clamping. Ann Thorac Surg 2006; 81:902-9. [PMID: 16488692 DOI: 10.1016/j.athoracsur.2005.09.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2005] [Revised: 09/05/2005] [Accepted: 09/09/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Paraplegia remains a devastating complication of thoracic aortic surgery, which has been attenuated by retrograde adenosine and systemic adenosine A2A receptor activation. We hypothesized that despite retrograde spinal perfusion of an adenosine A2A agonist (ATL-146e), systemic therapy produces superior spinal cord protection with reduced inflammation. METHODS Forty pigs underwent 30-minute thoracic aortic cross-clamping. Pigs received: no therapy (control); retrograde saline (retrograde control); retrograde ATL-146e; systemic ATL-146e; systemic ATL-146e with retrograde saline; or systemic and retrograde ATL-146e. Retrograde therapies were given during ischemia. Systemic ATL-146e (0.06 microg.kg(-1).min(-1)) was given intravenously for 3 hours at reperfusion. At 24 hours, motor function was assessed using the Tarlov scale. Tissue was analyzed for neuronal viability, microtubule-associated protein-2 expression, and neutrophil sequestration (myeloperoxidase activity). RESULTS Four pigs received retrograde barium showing both radiographic and histologic spinal cord perfusion. Tarlov scores at 24 hours were significantly improved versus both control groups in all ATL groups except the combined ATL-146e group (all p < 0.05). Neuronal viability by hematoxylin and eosin stain was significantly preserved in systemic ATL groups compared with both control groups (all p < 0.05). Microtubule-associated protein-2 expression was significantly preserved compared with both control groups in all systemic ATL groups. Systemic ATL significantly lowered myeloperoxidase activity versus both control groups (p < 0.01). CONCLUSIONS Both retrograde and systemic ATL-146e therapies attenuate ischemic spinal cord injury, but combining the two routes was less effective. Given comparable results between the two routes and the simplicity of systemic delivery, peripheral venous ATL-146e at reperfusion should be preferred for spinal cord protection in thoracic aortic surgery.
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Affiliation(s)
- T Brett Reece
- Department of Surgery, University of Virginia, Charlottesville, Virginia, USA.
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Toumpoulis IK, Papakostas JC, Matsagas MI, Malamou-Mitsi VD, Pappa LS, Drossos GE, Derose JJ, Anagnostopoulos CE. Superiority of early relative to late ischemic preconditioning in spinal cord protection after descending thoracic aortic occlusion. J Thorac Cardiovasc Surg 2005; 128:724-30. [PMID: 15514600 DOI: 10.1016/j.jtcvs.2004.06.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE We previously showed that ischemic preconditioning significantly reduced spinal cord injury caused by 35-minute aortic occlusion. In this study we investigated the effect of ischemic preconditioning on spinal cord injury after 45-minute aortic occlusion. METHODS Thirty-two pigs were divided as follows: group 1 (n = 6) underwent sham operation, group 2 (n = 6) underwent 20 minutes of aortic occlusion, group 3 (n = 6) underwent 45 minutes of occlusion, group 4 (n = 6) underwent 20 minutes of occlusion and 48 hours later underwent an additional 45 minutes, and group 5 (n = 8) underwent 20 minutes of occlusion and 80 minutes later underwent an additional 45 minutes. Aortic occlusion was accomplished with two balloon occlusion catheters placed fluoroscopically after the origin of the left subclavian artery and at the aortic bifurcation. Neurologic evaluation was by Tarlov score. The lower thoracic and lumbar spinal cords were harvested at 120 hours and examined histologically with hematoxylin-eosin staining. The number of neurons was counted, and the inflammation was scored (0-4). Statistical analysis was by Kruskal-Wallis and 1-way analysis of variance tests. RESULTS Group 5 (early ischemic preconditioning) had better Tarlov scores than group 3 ( P < .001) and group 4 (late ischemic preconditioning, P < .001). The histologic changes were proportional to the Tarlov scores, with the least histologic damage in the animals of group 5 relative to group 3 (number of neurons P < .001, inflammation P = .004) and group 4 (number of neurons P < .001, inflammation P = .006). CONCLUSION Early ischemic preconditioning is superior to late ischemic preconditioning in reducing spinal cord injury caused by the extreme ischemia of 45 minutes of descending thoracic aortic occlusion.
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Affiliation(s)
- Ioannis K Toumpoulis
- Department of Cardiothoracic Surgery, School of Medicine, University of Ioannina, Ioannina, Greece
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Reece TB, Okonkwo DO, Ellman PI, Warren PS, Smith RL, Hawkins AS, Linden J, Kron IL, Tribble CG, Kern JA. The evolution of ischemic spinal cord injury in function, cytoarchitecture, and inflammation and the effects of adenosine A2A receptor activation. J Thorac Cardiovasc Surg 2004; 128:925-32. [PMID: 15573078 DOI: 10.1016/j.jtcvs.2004.08.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Spinal cord ischemia/reperfusion injury involves multiple factors that may be modulated by adenosine A 2A receptor activation. This study defines injury progression in terms of function, cytoarchitecture, and inflammation and assesses whether adenosine A 2A receptor activation by ATL-146e limits injury progression. METHODS Mature swine were divided into 3 groups: sham thoracotomy, IR (30 minutes of ischemia followed by reperfusion), and ATL (ischemia/reperfusion with ATL-146e administration for the first 3 hours of reperfusion). Subgroups were killed at 0, 3, 6, 12, 24, and 48 hours after reperfusion. Function was followed up with Tarlov scores. Spinal cord tissue was evaluated for neuronal viability, microtubule-associated protein-2 immunohistochemistry, and neutrophil sequestration (myeloperoxidase assay). Spinal cord tissue, cerebrospinal fluid, and serum were evaluated for tumor necrosis factor-alpha by enzyme-linked immunosorbent assay. RESULTS Function was significantly impaired at 24, 36, and 48 hours in the IR group compared with the sham and ATL groups ( P < .05). Neuronal viability and microtubule-associated protein-2 staining were significantly preserved in the sham and ATL groups compared with the IR group at 24 and 48 hours ( P < .05). Spinal cord myeloperoxidase levels were significantly higher in the IR group than in the sham and ATL groups at 24 and 48 hours. Although negligible in serum and cerebrospinal fluid, tumor necrosis factor-alpha levels in the spinal cord peaked significantly higher in the IR group compared with the sham and ATL groups at 6 and 24 hours ( P < .05). CONCLUSIONS Spinal cord ischemia/reperfusion induced changes in neutrophil sequestration, microtubule-associated protein-2 expression, and neuronal viability within 24 hours of reperfusion. Spinal cord tumor necrosis factor-alpha increased significantly by 6 to 12 hours after reperfusion. Adenosine A 2A receptor activation attenuates spinal cord inflammation, which may be critical for the preservation of neuronal function and cytoarchitecture after ischemia/reperfusion.
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Affiliation(s)
- T Brett Reece
- Department of Surgery, University of Virginia Health System, PO Box 801359, Charlottesville, VA 22908, USA.
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Isquemia medular poscirugía de aneurisma torácico. Med Intensiva 2004. [DOI: 10.1016/s0210-5691(04)70102-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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