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Gharios M, Stenimahitis V, El-Hajj VG, Mahdi OA, Fletcher-Sandersjöö A, Jabbour P, Andersson M, Hultling C, Elmi-Terander A, Edström E. Spontaneous spinal cord infarction: a systematic review. BMJ Neurol Open 2024; 6:e000754. [PMID: 38818241 PMCID: PMC11138300 DOI: 10.1136/bmjno-2024-000754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 05/20/2024] [Indexed: 06/01/2024] Open
Abstract
Background and objectives Spontaneous spinal cord infarction (SCInf) is a rare condition resulting in acute neurological impairment. Consensus on diagnostic criteria is lacking, which may present a challenge for the physician. This review aims to analyse the current literature on spontaneous SCInf, focusing on epidemiology, the diagnostic process, treatment strategies and neurological outcomes. Methods The study was performed in accordance with a previously published protocol. PubMed, Web of Science and Embase were searched using the keywords 'spontaneous', 'spinal cord', 'infarction' and 'ischaemic'. The eligibility of studies was evaluated in two steps by multiple reviewers. Data from eligible studies were extracted and systematically analysed. Results 440 patients from 33 studies were included in this systematic review. Analysis of vascular risk factors showed that hypertension was present in 40%, followed by smoking in 30%, dyslipidaemia in 29% and diabetes in 16%. The severity of symptoms at admission according to the American Spinal Injury Association (ASIA) Impairment Scale was score A 19%, score B14%, score C36% and score D32%. The mean follow-up period was 34.8 (±12.2) months. ASIA score at follow-up showed score A 11%, score B 3%, score C 16%, score D 67% and score E 2%. The overall mortality during the follow-up period was 5%. When used, MRI with diffusion-weighted imaging (DWI) supported the diagnosis in 81% of cases. At follow-up, 71% of the patients were able to walk with or without walking aids. Conclusion The findings suggest a significant role for vascular risk factors in the pathophysiology of spontaneous SCInf. In the diagnostic workup, the use of DWI along with an MRI may help in confirming the diagnosis. The findings at follow-up suggest that neurological recovery is to be expected, with the majority of patients regaining ambulation. This systematic review highlights gaps in the literature and underscores the necessity for further research to establish diagnostic criteria and treatment guidelines.
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Affiliation(s)
- Maria Gharios
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Vasilios Stenimahitis
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Rehabilitation, Furuhöjden Rehab Hospital, Täby, Sweden
| | | | - Omar Ali Mahdi
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Magnus Andersson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Claes Hultling
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Adrian Elmi-Terander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Capio Spine Center Stockholm, Löwenströmska Hospital, Upplands-Väsby, Sweden
- Department of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Erik Edström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Capio Spine Center Stockholm, Löwenströmska Hospital, Upplands-Väsby, Sweden
- Department of Medical Sciences, Örebro University, Örebro, Sweden
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Kuru Bektaşoğlu P, Arıkök AT, Ergüder Bİ, Sargon MF, Altun SA, Ünlüler C, Börekci A, Kertmen H, Çelikoğlu E, Gürer B. Cinnamaldehyde has ameliorative effects on rabbit spinal cord ischemia and reperfusion injury. World Neurosurg X 2024; 21:100254. [PMID: 38148767 PMCID: PMC10750183 DOI: 10.1016/j.wnsx.2023.100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/14/2023] [Accepted: 11/28/2023] [Indexed: 12/28/2023] Open
Affiliation(s)
- Pınar Kuru Bektaşoğlu
- Department of Neurosurgery, University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Ata Türker Arıkök
- Department of Pathology, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | - Berrin İmge Ergüder
- Department of Biochemistry, Ankara University School of Medicine, Ankara, Turkey
| | - Mustafa Fevzi Sargon
- Department of Anatomy, Lokman Hekim University School of Medicine, Ankara, Turkey
| | - Seda Akyıldız Altun
- Department of Neurosurgery, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | - Caner Ünlüler
- Department of Neurosurgery, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | - Ali Börekci
- Istinye University Faculty of Medicine, Department of Neurosurgery, Istanbul, Turkey
| | - Hayri Kertmen
- Department of Neurosurgery, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | - Erhan Çelikoğlu
- Istinye University Faculty of Medicine, Department of Neurosurgery, Istanbul, Turkey
| | - Bora Gürer
- Istinye University Faculty of Medicine, Department of Neurosurgery, Istanbul, Turkey
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El-Hajj VG, Stenimahitis V, Gharios M, Mahdi OA, Elmi-Terander A, Edström E. Spontaneous spinal cord infarctions: a systematic review and pooled analysis protocol. BMJ Open 2023; 13:e071044. [PMID: 37344113 PMCID: PMC10314618 DOI: 10.1136/bmjopen-2022-071044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/09/2023] [Indexed: 06/23/2023] Open
Abstract
INTRODUCTION Spinal cord infarction (SCInf) is a rare ischaemic event that manifests with acute neurological deficits. It is typically classified as either spontaneous, defined as SCInf without any inciting event, or periprocedural, which typically occur in conjunction with vascular surgery with aortic manipulations. While periprocedural SCInf has recently been the subject of intensified research, especially focusing on the primary prevention of this complication, spontaneous SCInf remains less studied. METHODS AND ANALYSIS Electronic databases, including PubMed, Web of Science and Embase, will be searched using the keywords "spinal cord", "infarction", "ischemia" and "spontaneous". The search will be set to provide only English studies published from database inception. Editorials, letters and reviews will also be excluded. Reference lists of relevant records will also be searched. Identified studies will be screened for inclusion, by one reviewer in the first step and then three in the next step to decrease the risk of bias. The synthesis will address several topics of interest including epidemiology, presentation, diagnostics, treatment strategies, outcomes and predictors. The review aims to gather the body of evidence to summarise the current knowledge on SCInf. This will lead to a better understanding of the condition, its risk factors, diagnosis and management. Moreover, the review will also provide an understanding of the prognosis of patients with SCInf with respect to neurological function, quality of life and mortality. Finally, this overview of the literature will allow the identification of knowledge gaps to help guide future research efforts. ETHICS AND DISSEMINATION Ethics approval was not required for our review as it is based on existing publications. The final manuscript will be submitted to a peer-reviewed journal.
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Affiliation(s)
- Victor Gabriel El-Hajj
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Vasilios Stenimahitis
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Gharios
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Omar Ali Mahdi
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Adrian Elmi-Terander
- Stockholm Spine Center, Löwenströmska Hospital, Upplands-Väsby, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Erik Edström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Spine Center, Löwenströmska Hospital, Upplands-Väsby, Sweden
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Lee DW, Choi YH. Spinal cord infarction mimicking ischemic heart disease. Clin Exp Emerg Med 2017; 4:109-112. [PMID: 28717781 PMCID: PMC5511953 DOI: 10.15441/ceem.16.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/05/2017] [Accepted: 02/05/2017] [Indexed: 11/23/2022] Open
Abstract
Spinal cord infarction is a rare condition and is easily misdiagnosed owing to its initial non-specific manifestation. We report a case of a 77–year-old man who presented with chest pain and upper back pain initially, and was misdiagnosed with a myocardial infarction. Four hours after admission, he complained of numbness in his entire left leg below the knee, with rapid deterioration of neurological symptoms. After 9 hours, loss of sensation progressed up to the T4 dermatome, strength of both lower extremities deteriorated to grade 0, and decrease in anal tone and deep tendon reflex was observed. Initial magnetic resonance imaging findings were normal; however, a signal change occurred 3 days after symptom onset. When patients present with acute chest pain and neurologic symptoms, the possibility of ischemic cardiac disease as well as any neurological manifestations must be investigated. Emergency physicians must remember the value of serial physical examinations.
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Affiliation(s)
- Dae Won Lee
- Department of Emergency Medicine, Ewha WomansUniversity Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Yoon Hee Choi
- Department of Emergency Medicine, Ewha WomansUniversity Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
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Martirosyan NL, Patel AA, Carotenuto A, Kalani MYS, Bohl MA, Preul MC, Theodore N. The role of therapeutic hypothermia in the management of acute spinal cord injury. Clin Neurol Neurosurg 2017; 154:79-88. [PMID: 28131967 DOI: 10.1016/j.clineuro.2017.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 12/30/2016] [Accepted: 01/02/2017] [Indexed: 12/18/2022]
Abstract
This review paper investigates the history, efficacy, and administration of systemic and local hypothermia for spinal cord injury (SCI). It summarizes the published experimental and clinical evidence on hypothermia for SCI and analyzes the potential for further research. Early experimental animal research showed that local hypothermia improved recovery and gain of function after acute SCI. However, in the early 1970s, clinical research findings did not coincide with results of these animal trials, which led to a loss of interest in local hypothermia. Since the 1980s, systemic hypothermia has been successfully used to treat SCI in both animals and humans. An abundance of positive evidence suggests that clinical trials are needed to determine the effectiveness of hypothermia for SCI. As a first step, we investigated the published clinical and experimental evidence on the use of hypothermia for SCI patients, who have few available treatment options. We searched PubMed for English-language reports published from 1940 to 2016 containing terms related to SCI treatment using hypothermia. We reviewed all articles on local hypothermia and acute SCI or on systemic hypothermia and acute SCI. Bibliographies of retrieved publications were also screened for additional citations. Ninety-six papers were selected. The clinical use of hypothermia is most successful if applied according to certain optimized parameters (e.g., duration, temperature, time from injury to initiation of cooling, and rewarming time). Preliminary data suggest that modest systemic hypothermia applied for 48h provides the best therapeutic value, but the parameters for use of local hypothermia vary greatly. Experimental evidence and some clinical evidence suggest that both local hypothermia and systemic hypothermia are beneficial for acute SCI. Future research should focus on defining the optimal levels of parameters. Large, multicenter, controlled clinical trials are needed to investigate its therapeutic potential.
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Affiliation(s)
- Nikolay L Martirosyan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States; Division of Neurosurgery, University of Arizona, Tucson, AZ, United States
| | - Arpan A Patel
- College of Medicine, University of Arizona, Tucson, AZ, United States
| | | | - M Yashar S Kalani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Michael A Bohl
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States; Division of Neurosurgery, University of Arizona, Tucson, AZ, United States; College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Nicholas Theodore
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States.
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Murray MJ, De Ruyter ML, Torres NE, Lunn JJ, Harrison BA. Thoracoabdominal Aortic Aneurysm Repair: Reducing the Incidence of Paraplegia. Semin Cardiothorac Vasc Anesth 2016. [DOI: 10.1177/108925329900300106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Paraplegia is a major complication associated with repair of thoracoabdominal aortic aneurysms (TAAA). A number of therapies have been tried over the years, none of which has been successful. Recently, regional lumbar epidural cooling has been tried in an attempt to prolong the safe ischemic time during aortic cross- clamping. In approximately 90 patients in whom the authors have tried this technique, there was no de crease in the incidence of paraplegia in patients with type II TAAAs. This is perhaps not unanticipated be cause the paraplegia is related to a number of factors including the duration of the aortic cross-clamping, the adequacy of collateral circulation, embolization during the procedure, and perhaps thrombosis in situ. Given the multimodal cause of paraplegia, perhaps it is naive to think that a single therapy would be of benefit. Additional studies are necessary to explore the mecha nisms and to prove efficacy or lack of benefit of any techniques designed to decrease the incidence of paraplegia in patients undergoing TAAA repair.
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Goossens J, Hachimi-Idrissi S. Combination of therapeutic hypothermia and other neuroprotective strategies after an ischemic cerebral insult. Curr Neuropharmacol 2014; 12:399-412. [PMID: 25426009 PMCID: PMC4243031 DOI: 10.2174/1570159x12666140424233036] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 03/14/2014] [Accepted: 04/22/2014] [Indexed: 12/31/2022] Open
Abstract
Abrupt deprivation of substrates to neuronal tissue triggers a number of pathological events (the “ischemic cascade”) that lead to cell death. As this is a process of delayed neuronal cell death and not an instantaneous event, several pharmacological and non-pharmacological strategies have been developed to attenuate or block this cascade. The most promising neuroprotectant so far is therapeutic hypothermia and its beneficial effects have inspired researchers to further improve its protective benefit by combining it with other neuroprotective agents. This review provides an overview of all neuroprotective strategies that have been combined with therapeutic hypothermia in rodent models of focal cerebral ischemia. A distinction is made between drugs interrupting only one event of the ischemic cascade from those mitigating different pathways and having multimodal effects. Also the combination of therapeutic hypothermia with hemicraniectomy, gene therapy and protein therapy is briefly discussed. Furthermore, those combinations that have been studied in a clinical setting are also reviewed.
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Affiliation(s)
- Joline Goossens
- Critical Care Department and Cerebral Resuscitation Research Group, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Saïd Hachimi-Idrissi
- Critical Care Department and Cerebral Resuscitation Research Group, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
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Darwazeh R, Yan Y. Mild hypothermia as a treatment for central nervous system injuries: Positive or negative effects. Neural Regen Res 2014; 8:2677-86. [PMID: 25206579 PMCID: PMC4146029 DOI: 10.3969/j.issn.1673-5374.2013.28.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 07/17/2013] [Indexed: 12/15/2022] Open
Abstract
Besides local neuronal damage caused by the primary insult, central nervous system injuries may secondarily cause a progressive cascade of related events including brain edema, ischemia, oxida-tive stress, excitotoxicity, and dysregulation of calcium homeostasis. Hypothermia is a beneficial strategy in a variety of acute central nervous system injuries. Mild hypothermia can treat high intra-cranial pressure following traumatic brain injuries in adults. It is a new treatment that increases sur-vival and quality of life for patients suffering from ischemic insults such as cardiac arrest, stroke, and neurogenic fever following brain trauma. Therapeutic hypothermia decreases free radical produc-tion, inflammation, excitotoxicity and intracranial pressure, and improves cerebral metabolism after traumatic brain injury and cerebral ischemia, thus protecting against central nervous system dam-age. Although a series of pathological and physiological changes as well as potential side effects are observed during hypothermia treatment, it remains a potential therapeutic strategy for central nervous system injuries and deserves further study.
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Affiliation(s)
- Rami Darwazeh
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yi Yan
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Patel S, Naidoo K, Thomas P. Spinal cord infarction: a rare cause of paraplegia. BMJ Case Rep 2014; 2014:bcr-2013-202793. [PMID: 24966260 DOI: 10.1136/bcr-2013-202793] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Spinal cord infarction is rare and represents a diagnostic challenge for many physicians. There are few reported cases worldwide with a prevalence of 1.2% of all strokes. Circulation to the spinal cord is supplied by a rich anastomosis. The anterior spinal artery supplies the anterior two thirds of the spinal cord and infarction to this area is marked by paralysis, spinothalamic sensory deficit and loss of sphincter control depending on where the lesion is. Treatment of spinal cord infarction focuses on rehabilitation with diverse outcomes. This report presents a case of acute spinal cord infarction with acquisition of MRI to aid diagnosis.
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Affiliation(s)
- Sonali Patel
- Department of Accident and Emergency, Milton Keynes General Hospital, Milton Keynes, UK
| | - Khimara Naidoo
- Department of Accident and Emergency, Milton Keynes General Hospital, Milton Keynes, UK
| | - Peter Thomas
- Department of Accident and Emergency, Milton Keynes General Hospital, Milton Keynes, UK
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Gathwala G, Khera A, Singh J, Balhara B. Magnesium for neuroprotection in birth asphyxia. J Pediatr Neurosci 2011; 5:102-4. [PMID: 21559152 PMCID: PMC3087983 DOI: 10.4103/1817-1745.76094] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Magnesium ion gates the N-methyl-D-aspartate (NMDA) receptor and may protect the brain from NMDA receptor-mediated asphyxial injury. The present study evaluated the neuroprotective role of magnesium in birth asphyxia. Material and Methods: Forty term neonates with severe birth asphyxia were randomized to either the study group or the control group. Neonates in the study group received magnesium sulfate in a dose of 250 mg/kg initially within half an hour of birth followed by 125 mg/kg at 24 and 48 h of birth. Cranial computed tomography (CT) scan and electroencephalography (EEG) were performed for all the babies. Denver II was used for developmental assessment at the age of 6 months. Results: Two babies in each group died of severe hypoxic ischemic encephalopathy. EEG abnormalities occurred in 43.75% of the cases in the control group compared with 31.25% in the study group. CT scan abnormalities were present in 62.5% of the control group compared with 37.5% of the cases in the study group. The Denver II assessment at 6 months revealed that there were five babies that were either abnormal or suspect in the control group compared with three in the study group. Conclusion: Magnesium is well tolerated and does appear to have beneficial effects in babies with severe asphyxia. More data is however needed and a large multicenter trial should be conducted.
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Affiliation(s)
- Geeta Gathwala
- Department of Pediatrics, Neonatal Services Division, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, University of Health Sciences, Rohtak, Haryana, India
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Abstract
Spinal cord injury (SCI) is a devastating condition that affects approximately 11,000 patients each year in the United States. Although a significant amount of research has been conducted to clarify the pathophysiology of SCI, there are limited therapeutic interventions that are currently available in the clinic. Moderate hypothermia has been used in a variety of experimental and clinical situations to target several neurological disorders, including traumatic brain and SCI. Recent studies using clinically relevant animal models of SCI have reported the efficacy of therapeutic hypothermia (TH) in terms of promoting long-term behavioral improvement and reducing histopathological damage. In addition, several clinical studies have demonstrated encouraging evidence for the use of TH in patients with a severe cervical spinal cord injury. Moderate hypothermia (33°C) introduced systemically by intravascular cooling strategies appears to be safe and provides some improvement of long-term recovery of function. TH remains an experimental clinical approach and randomized multicenter trials are needed to critically evaluate this potentially exciting therapeutic intervention targeting this patient population.
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Affiliation(s)
- W Dalton Dietrich
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL 33136-1060, USA.
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Acher C. It is not just assisted circulation, hypothermic arrest, or clamp and sew. J Thorac Cardiovasc Surg 2010; 140:S136-41; discussion S142-S146. [DOI: 10.1016/j.jtcvs.2010.07.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 07/12/2010] [Indexed: 10/18/2022]
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The use of systemic hypothermia for the treatment of an acute cervical spinal cord injury in a professional football player. Spine (Phila Pa 1976) 2010; 35:E57-62. [PMID: 20081503 DOI: 10.1097/brs.0b013e3181b9dc28] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case Report. OBJECTIVE We will describe the injury and clinical course of an NFL Football player who sustained a complete spinal cord injury and was treated with conventional care in addition to modest systemic hypothermia. SUMMARY OF BACKGROUND DATA Systemically induced moderate hypothermia is a potentially neuroprotective intervention in acute spinal cord injury. However, case descriptions of human patients receiving systemic hypothermia after spinal cord injuries are lacking in the literature. METHODS Here, we present the case of a National Football League player who sustained a complete (ASIA A) spinal cord injury from a C3/4 fracture dislocation. Moderate systemic hypothermia was instituted immediately after his injury, in addition to standard medical/surgical treatment, including, surgical decompression and intravenous methylprednisolone. RESULTS The patient experienced significant and rapid neurologic improvement, and within weeks of his injury was walking with harness assistance. Since that time, the patient has continued to make significant progress in his rehabilitation (now ASIA D). CONCLUSION The extent to which this hypothermia contributed to his neurologic recovery is difficult to determine. It is hoped that this case will draw attention to the need for further preclinical and clinical studies to elucidate the role of hypothermia in acute spinal cord injury. Until these studies are completed, it is impossible to advocate for systemic hypothermia as a standard of care.
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Dietrich WD, Atkins CM, Bramlett HM. Protection in animal models of brain and spinal cord injury with mild to moderate hypothermia. J Neurotrauma 2009; 26:301-12. [PMID: 19245308 DOI: 10.1089/neu.2008.0806] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
For the past 20 years, various laboratories throughout the world have shown that mild to moderate levels of hypothermia lead to neuroprotection and improved functional outcome in various models of brain and spinal cord injury (SCI). Although the potential neuroprotective effects of profound hypothermia during and following central nervous system (CNS) injury have long been recognized, more recent studies have described clinically feasible strategies for protecting the brain and spinal cord using hypothermia following a variety of CNS insults. In some cases, only a one or two degree decrease in brain or core temperature can be effective in protecting the CNS from injury. Alternatively, raising brain temperature only a couple of degrees above normothermia levels worsens outcome in a variety of injury models. Based on these data, resurgence has occurred in the potential use of therapeutic hypothermia in experimental and clinical settings. The study of therapeutic hypothermia is now an international area of investigation with scientists and clinicians from every part of the world contributing to this important, promising therapeutic intervention. This paper reviews the experimental data obtained in animal models of brain and SCI demonstrating the benefits of mild to moderate hypothermia. These studies have provided critical data for the translation of this therapy to the clinical arena. The mechanisms underlying the beneficial effects of mild hypothermia are also summarized.
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Affiliation(s)
- W Dalton Dietrich
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida 33136-1060, USA.
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Juvonen T, Biancari F, Rimpiläinen J, Satta J, Rainio P, Kiviluoma K. Strategies for Spinal Cord Protection during Descending Thoracic and Thoracoabdominal Aortic Surgery: Up-to-date Experimental and Clinical Results - A review. SCAND CARDIOVASC J 2009. [DOI: 10.1080/cdv.36.3.136.160] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Lo TP, Cho KS, Garg MS, Lynch MP, Marcillo AE, Koivisto DL, Stagg M, Abril RM, Patel S, Dietrich WD, Pearse DD. Systemic hypothermia improves histological and functional outcome after cervical spinal cord contusion in rats. J Comp Neurol 2009; 514:433-48. [DOI: 10.1002/cne.22014] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Wartenberg KE, Mayer SA. Use of induced hypothermia for neuroprotection: indications and application. FUTURE NEUROLOGY 2008. [DOI: 10.2217/14796708.3.3.325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Therapeutic temperature regulation has become an exciting field of interest. Mild-to-moderate hypothermia is a safe and feasible management strategy for neuroprotection and control of intracranial pressure in neurological catastrophies such as traumatic brain injury, subarachnoid and intracerebral hemorrhage, and large hemispheric stroke. Fever is associated with worse neurological outcome in patients with brain injury, normothermia may be of benefit in this patient population. The efficacy of mild-to-moderate hypothermia has been proven for neuroprotection after cardiac arrest with ventricular fibrillation as initial rhythm, and after neonatal asphyxia. Application of hypothermia and fever control in neurocritical care, available cooling technologies and systemic effects and complications of hypothermia will be discussed.
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Affiliation(s)
- Katja E Wartenberg
- University Hospital Carl Gustav Carus Dresden, Neurointensive Care Unit, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Stephan A Mayer
- Columbia University, Dept of Neurosurgery, 710 W 168th Street, New York, NY 10032, USA
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Kiymaz N, Yilmaz N, Mumcu C, Anlar O, Ozen S, Kayaoğlu CR. Protective effect of sildenafil (Viagra) in transient spinal cord ischemia. Pediatr Neurosurg 2008; 44:22-8. [PMID: 18097187 DOI: 10.1159/000110658] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2006] [Accepted: 04/11/2007] [Indexed: 11/19/2022]
Abstract
Prospective study of the neuroprotective activity of sildenafil in a rat spinal ischemia model. The present study involved 21 male Sprague-Dawley rats. The animals were divided into 3 groups. Physiological serum was administered intraperitoneally to the 8 rats in the control group at the beginning of reperfusion for a period of 20 min after abdominal aortal occlusion. Sildenafil (Viagra) was administered as a single 10-mg/kg/day intraperitoneal dose to the 8 rats in the sildenafil group at the beginning of reperfusion after 20 min of abdominal aortal occlusion. No occlusion was performed and no agent was administered to the 5 rats in the sham group, but the abdominal aorta was reached by means of surgical intervention. Before the animals were sacrificed, several physiological and biochemical parameters were investigated, preoperative and postoperative motor functions were also assessed, and somatosensory evoked potential (SEP) monitoring and histopathological examinations were carried out. No differences were found between the physiological and biochemical parameters in each of the 3 groups. Neurological scoring performed after reperfusion demonstrated a significant improvement in the neurological results relative to those of the control group over 48 h in subjects that received sildenafil. These animals also showed better 24-hour SEP results, measured in terms of extended latency and decreased amplitude, than the control animals. A histopathological study showed reduced ischemic symptoms in rats that received sildenafil compared with those in the control group. However, no anomalies were observed in the sham group with respect to the histopathological and neurological findings. These results indicate that neurological damage due to spinal-cord ischemia-reperfusion injury can be reduced by sildenafil.
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Affiliation(s)
- Nejmi Kiymaz
- Department of Neurosurgery, Yuzuncu Yil University, Medical School, Van, Turkey
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Kahn RA, Stone ME, Moskowitz DM. Anesthetic consideration for descending thoracic aortic aneurysm repair. Semin Cardiothorac Vasc Anesth 2007; 11:205-23. [PMID: 17711972 DOI: 10.1177/1089253207306098] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Anesthesia for surgery of the aorta poses some of the most difficult challenges for anesthesiologists. Major hemodynamic and physiologic stresses and sophisticated techniques of extracorporeal support are superimposed on patients with complex medical disease states. In this review, etiologies, natural history, and surgical techniques of thoracic aortic aneurysm are presented. Anesthetic considerations are discussed in detail, including the management of distal perfusion using partial cardiopulmonary bypass. Considerations of spinal cord protection, including management of proximal hypertension, cerebral spinal fluid drainage, and pharmacological therapies, are presented.
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Affiliation(s)
- Ronald A Kahn
- Department of Anesthesiology, the Mount Sinai School of Medicine, New York, New York 10029-6547, USA.
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21
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Kohno H, Ishida A, Imamaki M, Shimura H, Miyazaki M. Efficacy and vasodilatory benefit of magnesium prophylaxis for protection against spinal cord ischemia. Ann Vasc Surg 2007; 21:352-9. [PMID: 17484971 DOI: 10.1016/j.avsg.2007.01.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2006] [Revised: 01/12/2007] [Accepted: 01/29/2007] [Indexed: 11/20/2022]
Abstract
Prevention of paraplegia remains an imperative issue in thoracoabdominal aortic surgery. The aim of this study was to assess the efficacy of a prophylactic magnesium infusion in a rat spinal cord ischemia model and to demonstrate spinal blood flow increase caused by the infusion. The study was conducted in two parts. Firstly, the neuroprotective effect of magnesium was assessed using a rat model with two different ischemic times: 10 min and 14 min. Spinal cord ischemia was induced by occlusion of the descending aorta. Rats in the treatment group were given a 100 mg/kg magnesium sulfate infusion before ischemia. Secondly, relative changes in spinal cord blood flow before and during ischemia were recorded using the laser Doppler flowmetry technique. Changes in blood flow were compared between the magnesium and control groups. Rats pretreated with magnesium showed good overall recovery after both 10 min (incidence of paraplegia 62.5% control vs. 37.5% Mg, n = 8 each) and 14 min (85.7% control vs. 57.1% Mg, n = 7 each) of ischemia, although the differences compared with controls were statistically insignificant. However, the magnesium group showed significantly better neurological performance during the early postischemic period. Comparison of changes in spinal circulation revealed less reduction in blood flow during ischemia in the magnesium-treated group. In conclusion, magnesium may have potential prophylactic benefits during ischemia by exerting a neuroprotective effect through vasodilation of the spinal cord vasculature. To our knowledge, this vasodilatory effect on the spinal cord has not previously been investigated. Optimization of the treatment regimen, however, is required.
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Affiliation(s)
- Hiroki Kohno
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan.
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Furlan JC, Fehlings MG. A Web-based systematic review on traumatic spinal cord injury comparing the "citation classics" with the consumers' perspectives. J Neurotrauma 2006; 23:156-69. [PMID: 16503800 DOI: 10.1089/neu.2006.23.156] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Although the citation index of an article is not a direct measure of its quality or importance, it is a measure of recognition that may suggest its impact on the scientific community. This study was undertaken to examine the characteristics of the top 100 most frequently cited articles (so-called "citation classics") on traumatic spinal cord injury (SCI) that were published between 1986 and 2003, and to compare this selected professional literature with the consumers' perspective on the key issues in SCI research. The 100 top-cited articles on traumatic SCI were identified using the Internet database of the Science Citation Index Expanded and the Web of Science with the terms "spinal cord injury" and "spinal cord injuries." Meeting abstracts, letters, and editorials were excluded. No language restriction was applied. From a consumers' perspective, the areas of greatest interest for people with SCI as reported in two previous large-scale surveys include motor function, bowel and bladder control, sexual function, and pain. The final list of citation classics on traumatic SCI included 82 original articles and 18 article reviews, which were cited 146 times on average. Topics on basic science (63%) were more frequent than clinical studies (37%). The years of publication were distributed in a bell-shape curve with a peak between 1992 and 1994. North American and European centers (99%) led the list of the citation classics. Most of the top 100 most frequently cited articles on traumatic SCI (63%) explicitly focused on at least one of the topics of greatest interest to individuals with SCI. Motor function was the leading topic in the matching list between professional literature and consumers' perspective. This bibliometric analysis, for the first time, identifies the key features of the citation classics on traumatic SCI between 1986 and 2003, a period that represents one of an unprecedented increase in knowledge in this field. The 100 top-cited peer-reviewed articles have been predominantly focused on basic science SCI research indicating a need for greater bench-to-bedside translational studies in SCI research. Although the body of this top-cited professional literature mostly matches with the consumers' perspective, most of this research has been focused on motor function assessment and recovery following SCI.
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Affiliation(s)
- Julio C Furlan
- Department of Surgery, Division of Neurosurgery, University of Toronto, Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Abstract
OBJECTIVE Glutamate plays a critical role in the hypoxic ischaemic neuronal death. Two mechanisms of glutamate- induced neuronal death have been identified. One is rapid cell death that occurs in minutes and the second is delayed cell death that occurs over hours and is initiated principally by the activation of the N-methyl D-Aspactate (NMDA) receptor. Magnesium (Mg) is an NMDA receptor blocker. Systemic administration of Mg after a simulated hypoxic ischaemic insult has been shown to limit neuronal injury in several animal models. However, before embarking on to the use of Mg for neuronal protection in the human neonate it is important to study the safety and side effects of Mg administration. METHODS Forty terms, appropriate for gestational age babies with severe birth asphyxia (1 min Apgar score < 3 and 5 min Apgar score < 6), were randomly assigned to either the study group or the control group. Infants in both groups were treated as per unit protocol except that babies in the study group received intravenous injection of magnesium sulphate 250 mg/kg within half an hour of birth and subsequently 125 mg/kg at 24 and 48 hours of life. RESULTS The mean cord blood serum Mg levels were 0.78 (+/- 0.047) mmol/L in the control group and 0.779(+/-0.045) mmol/L in the study group. The serum Mg levels at 3, 6, 12, 24, 48 and 72 hours of life were 1.87(+/-0.6), 1.65(+/-0.059), 1.468 (+/-0.91), 1.881 (+/- 0.053), 1.916 (+/- 0.053) and 1.493 (+/- 0.084) mmol/L respectively in the study group. All these values were significantly higher than those obtained in the control group (p< 0.001). No significant alterations in heart rate, respiratory rate, oxygen saturation and mean arterial pressure were seen, following magnesium infusion with either 250 mg/kg or 125 mg/kg dose. The serum Mg levels in the study group ranged between 1.493 (+/- 0.084) and 1.916(+/-0.053) mmol/L, which are considered to be in the neuroprotective range. CONCLUSION Injection MgSO4 administered in a dose of 250 mg/kg and 125 mg/kg as an intravenous infusion is safe and the Mg levels obtained are in the range considered to be neuroprotective.
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Lee JC, Hwang IK, Park SK, Yoo KY, Seo K, Kang TC, Oh YS, Won MH. Histochemical and Electron Microscopic Study on Motor Neurone Degeneration Following Transient Spinal Cord Ischaemia at Normothermic Conditions in Rabbits. Anat Histol Embryol 2005; 34:252-7. [PMID: 15996127 DOI: 10.1111/j.1439-0264.2005.00603.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This study was carried out to investigate the motor neurone degeneration in the ventral horn following transient spinal cord ischaemia at normothermic conditions in rabbits. Transient spinal cord ischaemia was induced by occlusion of the abdominal aorta underneath the left renal artery for 15 min at normothermia (38.7 degrees C). Sections at the level of L7 were examined using histochemical and electron microscopic methods. Cresyl violet-positive motor neurones began to reduce in number at 3 h after ischaemia reperfusion, and were not detectable at 48 h after ischaemia reperfusion. Acid fuchsin-positive motor neurones were detected at 1 h after ischaemia reperfusion, significantly increased up to 6 h after the ischaemia reperfusion, and eventually disappeared by 48 h after ischaemia reperfusion. In electron microscopic findings, the disintegration of cytoplasmic membranes, and the disruption of mitochondria and endoplasmic reticulum were observed in motor neurones at 30 min after ischaemia reperfusion. Motor neurones showed necrotic findings with pyknotic degeneration at 1 h after ischaemia reperfusion. The necrotic degeneration became severer time dependently after ischaemia reperfusion. At 48 h after ischaemia reperfusion, cellular components were not detectable in motor neurones. In conclusion, we suggest that the degeneration pattern of motor neurones of the ischaemic spinal cord was necrotic after ischaemia reperfusion under normothermic conditions.
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Affiliation(s)
- J-C Lee
- Department of Pharmacology, Ewha Medical School, Ewha Institute of Neuroscience, Ewha Womans University, Seoul 110-783, South Korea
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Freye E. Cerebral Monitoring in the Operating Room and the Intensive Care Unit – An Introductory for the Clinician and a Guide for the Novice Wanting to Open a Window to the Brain. J Clin Monit Comput 2005; 19:77-168. [PMID: 16167223 DOI: 10.1007/s10877-005-0713-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
An evoked potential differs from the EEG mainly in two ways: 1. The EEG is a random, continuous signal, which arises from the ongoing activity of the outer layers of the cortex. An evoked potential is the brain's response to a repetitive stimulus along a specific nerve pathway. 2.EEG signals range from 10-200 milliVolt (mV). Evoked potentials are smaller in amplitude (1-5-20 microVolt requiring precise electrode positioning and special techniques (signal averaging) to extract the specific response from the underlying EEG "noise". The technique of signal averaging, as originally described by Dawson in 1954 [69J, has been further developed in computer processing. The technique is now used by applying a stimulus repeatedly--preferably at randomized intervals--and to record the evoked response over the corresponding area of the brain, averaging out mathematically the change over the number of stimuli. Rationale for the use of EPs in the OR and the ICU. Evoked potentials (EPs) serve the following major purposes: 1. Monitoring of the functional integrity of neural structures that may be at risk during, for instance, ECC (extracorporeal circulation) or endarterectomy indicating cerebral hypoxia. 2. Monitoring of the effects of anesthetic agents and other centrally active drugs, which, besides the cortex, affect deeper neuronal structures. 3. Orthopedic cases where the spinal cord is at risk such as Harrington rod insertion and removal. 4. Clamping of the abdominal aortic artery during aneurysmectomy resulting in a potential damage of the lower parts of the spinal cord. 5. Clipping of an intracerebral aneurysm, which may be impeding blood flow to vital cerebral textures. 6. An indicator of cerebral hypoxia when the blood pressure is deliberately lowered. 7. Operation on peripheral nerves and nerve roots to identify early trauma. 8. Monitoring the cerebral function during controlled hypothermia when the EEG becomes flat. 9. Monitoring of the pathophysiological conditions after severe head trauma and the effects of therapy. 10. An intraoperative warning device of unsuspected awareness during light anesthesia when movement is abolished by muscle relaxants and cardiovascular responses are modified by vasoactive drugs. In case of the latter the stimulus is a small electrical potential applied to the skin of the hand. Thereafter, the stimulus travels along the specific nervous pathways inducing (= generating) potential activation at various sites. The generation of potential changes at various sites along the pathway is an index for the integrity of the nerve. Thus, the evoked potential can be considered a neurophysiological response (usually of the cortex) to impulses originating from some externally stimulated sensory nerve. They provide a physiological measure of the functional integrity of the sensory nerve pathway, which can be used as a clinical diagnostic tool as well as for intraoperative monitoring. The evoked potential usually is recorded from the specific cortical area corresponding to the stimulus input. The classification of evoked potentials. Stimulating a sensory nervous pathway induces evoked potentials. If the auditory nerve is stimulated by "clicks" from headphones, it is called the auditory evoked potential (AEP). The early part of the AEP waveform (less than 10 msec) is called the Brainstem Auditory Evoked Potential (BAEP) since it reflects the passing of the impulse through the brainstem. If a nerve on the arm or the leg is stimulated by a small electrical current applied to the overlying skin, it is called the Somatosensory Evoked Potential (SSEP). If, however, the retina is stimulated by means of flicker light or a sudden change in a checkerboard pattern, the evoked potential thus recorded over the corresponding cortical area is called the Visual Evoked Potential (VEP). Evoked potentials are used both as a diagnostic tool and as a monitoring technique. As diagnostic tests, evoked potentials are useful to evaluate neurologic disorders such as: a) multiple sclerosis, b) acoustic nerve tumors, and c) optic neuritis. As a monitoring modality, evoked potentials are used during all surgical procedures, which might compromise part of the brain or the spinal cord.
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Affiliation(s)
- Enno Freye
- Clinics of Vascular Surgery and Renal Transplantation, Heinrich-Heine-University-Düsseldorf, Deichstrasse 3a, 41468 Neuss-Uedesheim, Germany.
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Casas CE, Herrera LP, Prusmack C, Ruenes G, Marcillo A, Guest JD. Effects of epidural hypothermic saline infusion on locomotor outcome and tissue preservation after moderate thoracic spinal cord contusion in rats. J Neurosurg Spine 2005; 2:308-18. [PMID: 15796356 DOI: 10.3171/spi.2005.2.3.0308] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Object. Regionally delivered hypothermia has advantages over systemic hypothermia for clinical application following spinal cord injury (SCI). The effects of local hypothermia on tissue sparing, neuronal preservation, and locomotor outcome were studied in a moderate thoracic spinal cord contusion model.
Methods. Rats were randomized to four treatment groups and data were collected and analyzed in a blinded fashion. Chilled saline was perfused into the epidural space 30 minutes postcontusion to achieve the following epidural temperatures: 24 ± 2.3°C (16 rats), 30 ± 2.4°C (13 rats), and 35 ± 0.9°C (13 rats). Hypothermia was continued for 3 hours when a 45-minute period of rewarming was instituted. In a fourth group a moderate contusion only was induced in 14 animals. Rectal (core) and T9–10 (epidural) temperatures were measured continuously. Locomotor testing, using the Basso-Beattie-Bresnahan (Ba-Be-Br) scale, was performed for 6 weeks, and rats were videotaped for subsequent analysis. The lesion/preserved tissue ratio was calculated throughout the entire lesion cavity and the total lesion, spinal cord, and spared tissue volumes were determined. The rostral and caudal extent of gray matter loss was also measured. At 6 weeks locomotor recovery was similar in all groups (mean Ba-Be-Br Scale scores 14.88 ± 3.71, 14.83 ± 2.81, 14.50 ± 2.24, and 14.07 ± 2.39 [p = 0.77] for all four groups, respectively). No significant differences in spared tissue volumes were found when control and treatment groups were compared, but gray matter preservation was reduced in the infusion-treated groups.
Conclusions. Regional cooling applied 30 minutes after a moderate contusive SCI was not beneficial in terms of tissue sparing, neuronal preservation, or locomotor outcome. This method of cooling may reduce blood flow in the injured spinal cord and exacerbate secondary injury.
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Affiliation(s)
- Carlos E Casas
- The Miami Project to Cure Paralysis, Department of Neurological Surgery, University of Miami, Florida 33136, USA
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Polderman KH. Application of therapeutic hypothermia in the ICU: opportunities and pitfalls of a promising treatment modality. Part 1: Indications and evidence. Intensive Care Med 2004; 30:556-75. [PMID: 14767591 DOI: 10.1007/s00134-003-2152-x] [Citation(s) in RCA: 216] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2003] [Accepted: 12/18/2003] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Hypothermia has been used for medicinal purposes since ancient times. This paper reviews the current potential clinical applications for mild hypothermia (32-35 degrees C). DESIGN AND SETTING Induced hypothermia is used mostly to prevent or attenuate neurological injury, and has been used to provide neuroprotection in traumatic brain injury, cardiopulmonary resuscitation, stroke, and various other disorders. The evidence for each of these applications is discussed, and the mechanisms underlying potential neuroprotective effects are reviewed. Some of this evidence comes from animal models, and a brief overview of these models and their limitations is included in this review. RESULTS The duration of cooling and speed of re-warming appear to be key factors in determining whether hypothermia will be effective in preventing or mitigating neurological injury. Some other potential usages of hypothermia, such as its use in the peri-operative setting and its application to mitigate cardiac injury following ischemia and reperfusion, are also discussed. CONCLUSIONS Although induced hypothermia appears to be a highly promising treatment, it should be emphasized that it is associated with a number of potentially serious side effects, which may negate some or all of its potential benefits. Prevention and/or early treatment of these complications are the key to successful use of hypothermia in clinical practice. These side effects, as well as various physiological changes induced by cooling, are discussed in a separate review.
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Affiliation(s)
- Kees H Polderman
- Department of Intensive Care, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
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Coady MA, Mitchell RS. Femoro-femoral partial bypass in the treatment of thoracoabdominal aneurysms. Semin Thorac Cardiovasc Surg 2003; 15:340-4. [PMID: 14710375 DOI: 10.1053/s1043-0679(03)00089-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article describes our rationale for the use of femoro-femoral bypass as a primary modality for perfusion in the repair of thoracoabdominal aortic aneurysms at Stanford University School of Medicine. Benefits and limitations of this method are discussed and compared with other described techniques.
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Affiliation(s)
- Michael A Coady
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Falk Cardiovascular Research Center, Palo Alto, CA 94305-5407, USA
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Kaptanoglu E, Beskonakli E, Solaroglu I, Kilinc A, Taskin Y. Magnesium sulfate treatment in experimental spinal cord injury: emphasis on vascular changes and early clinical results. Neurosurg Rev 2003; 26:283-7. [PMID: 12783273 DOI: 10.1007/s10143-003-0272-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2002] [Accepted: 02/11/2003] [Indexed: 10/26/2022]
Abstract
Injury to the spinal cord results in disruption of neurons, cell membranes, axons, myelin, and endothelial cells. The aim of this study was to demonstrate the protective effect of magnesium sulfate on the blood-spinal cord barrier after acute spinal cord injury (SCI). This experiment was conducted in two parts. In the first, rats were injected intravenously with Evans blue 2 h after SCI. The laminectomy-only group had no trauma. Contusion injury (50 g-cm) was applied to the trauma and treatment groups. Magnesium sulfate (600 mg/kg) was given to the treatment group immediately after injury. For the second part, clinical evaluations were performed 24 h post surgery. Then, following Evans blue injection, spinal cord samples were obtained from the laminectomy-only, trauma, and treatment groups. For the control group, nontraumatized spinal cord samples were taken after Evans blue injection following clinical examination. Laminectomy did not affect the spinal cord Evans blue content in 2-h and 24-h groups. The trauma increased tissue Evans blue content, and 24-h samples showed more remarkable tissue Evans blue content, suggesting secondary injury. Application of 600 mg/kg of magnesium resulted in lower Evans blue content in the spinal cord than with injury. Remarkable clinical neuroprotection was observed in the treatment groups. Magnesium sulfate showed vaso- and neuroprotective properties after contusion injury to the rat spinal cord. The authors also demonstrated secondary injury of the blood-spinal cord barrier with the Evans blue clearance technique for the first time.
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Affiliation(s)
- Erkan Kaptanoglu
- Department of Neurosurgery, Ankara Numune Education and Research Hospital, Ankara, Turkey
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Kaptanoglu E, Beskonakli E, Okutan O, Selcuk Surucu H, Taskin Y. Effect of magnesium sulphate in experimental spinal cord injury: evaluation with ultrastructural findings and early clinical results. J Clin Neurosci 2003; 10:329-34. [PMID: 12763339 DOI: 10.1016/s0967-5868(03)00031-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Excitotoxic mechanisms have been implicated in the pathophysiology of spinal cord injury (SCI). The authors have studied the protection against secondary damage to rat spinal cord with magnesium sulphate, a well-known N-methyl-D-aspartate antagonist. Rats were randomly allocated into 5 groups. Group 1 rats were controls and normal spinal cord samples were obtained after clinical examination. 50 g-cm contusion injury was introduced to Group 2. Group 3 was vehicle, 1 cc of physiologic saline was injected post-trauma. Group 4 and 5 were treatment groups and 100 mg/kg and 600 mg/kg of Magnesium sulphate was given immediately after trauma, intraperitoneally. Animals were evaluated with inclined plane, Tarlov motor scale and Basso-Beattie-Bresnahan scale 24h after SCI. Spinal cord samples for ultrastructural evaluations were obtained following clinical examinations. Magnesium treatment improved neurological outcome. Electron microscopic results showed obvious neuroprotection in the treatment groups. Application of 600 mg/kg of magnesium revealed better ultrastructural findings and clinical results than 100 mg/kg. These findings demonstrated that magnesium sulphate possesses neuroprotection on spinal cord ultrastructure and on functional scores after acute contusion injury to the rat spinal cord.
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Affiliation(s)
- Erkan Kaptanoglu
- Department of Neurosurgery, Ankara Numune Education, and Research Hospital, Ankara, Turkey
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Tetik O, Islamoğlu F, Göncü T, Cekirdekçi A, Büket S. Reduction of spinal cord injury with pentobarbital and hypothermia in a rabbit model. Eur J Vasc Endovasc Surg 2002; 24:540-4. [PMID: 12443752 DOI: 10.1053/ejvs.2002.1753] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to evaluate the effects of hypothermia and pentobarbital on spinal cord ischaemia induced in a rabbit model. MATERIALS AND METHODS thirty-two rabbits, allocated into four equal groups, had the infrarenal aorta clamped distal to the left renal artery and above the iliac bifurcation for 40 min. Groups 3 and 4 had infusion of 15 mg/kg of pentobarbital intravenously for 5 min, 15 min before the cross-clamping. Groups 2 and 4 had infusion of 20 ml of Ringer's lactate (LR) solution at 3 degrees C for 3 min during aortic cross clamp into the isolated aortic segment. Group 1 was untreated and served as control. Postoperative functions of spinal cord were assessed. RESULTS paraplegia occurred in all rabbits in Group 1, in one in each of Groups 2 and 3, whereas no paraplegia was observed in Group 4. In addition 2 and 3 animals of Groups 2 and 3, respectively revealed varying degree of neurological disturbances, whereas all animals of Group 4 had normal function. This difference between Groups 2, 3, and 4 vs Group 1 was significant (p<0.002). So was the difference between Groups 2 and 4 (p=0.03), whereas the difference between Groups 3 and 4 was not significant. CONCLUSIONS hypothermia and pentobarbital was more effective than hypothermia alone for prevention of spinal cord ischaemia in a rabbit model.
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Affiliation(s)
- O Tetik
- Department of Cardiovascular Surgery, Atatürk Medical Research Hospital, Izmir, Turkey
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Yu WR, Westergren H, Farooque M, Holtz A, Olsson Y. Systemic hypothermia following compression injury of rat spinal cord: An immunohistochemical study on the expression of vimentin and GFAP. Neuropathology 2002. [DOI: 10.1046/j.1440-1789.1999.00227.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Wen Ru Yu
- Research Group of Neuropathology, Department of Genetics and Pathology and,
| | - Hans Westergren
- Unit of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Mohammad Farooque
- Research Group of Neuropathology, Department of Genetics and Pathology and,
| | - Anders Holtz
- Unit of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Yngve Olsson
- Research Group of Neuropathology, Department of Genetics and Pathology and,
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Abstract
Delayed neuronal death following hypoxic ischaemic insult is primarily mediated by the N-methyl D-aspartate (NMDA) receptor. The NMDA receptor antagonist MK 801, has been shown to limit neuronal death following hypoxic ischaemic injury but is too toxic to be used in the human neonate. Magnesium blocks the NMDA channel in a voltage dependent manner. Its administration after a simulated hypoxic ischaemic insult limits neurological damage in several animal models. The efficacy of magnesium in providing neuroprotection in the human neonate, however needs to be established in controlled clinical trials.
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Affiliation(s)
- G Gathwala
- Neonatology Unit, Department of Paediatrics, Pt. Baghwat Dayal Sharma PGIMS, Rohtak, India
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Kazama S, Miyoshi Y, Nie M, Imai H, Lin ZB, Kurata A, Machii M. Protection of the spinal cord with pentobarbital and hypothermia. Ann Thorac Surg 2001; 71:1591-5. [PMID: 11383805 DOI: 10.1016/s0003-4975(00)02546-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Ischemic spinal cord damage during thoracic aortic operations has not been eliminated despite application of various adjuncts. We experimentally investigated the protective effects of pentobarbital and hypothermia on the spinal cord subjected to ischemia. METHODS Among nine groups of 6 rabbits each, groups AI to AIII underwent 20-minute infrarenal aortic occlusion, and groups BI to BVI underwent 40-minute occlusion. Five milligrams per kilogram of pentobarbital was administered to groups AII and BII; 10 mg/kg in groups AIII, BIII, and BVI; 20 mg/kg in group BIV; and none in groups AI, BI, and BV. In groups BV and BVI, hypothermia was induced. Forty-eight hours postoperatively, the motor function of the lower limbs was evaluated. RESULTS Statistically significant recovery of motor function was observed in animals in groups AII, AIII, BIII, BIV, BV, and BVI. CONCLUSIONS Pentobarbital showed dose-dependent protective effects of the spinal cord. Moderate hypothermia alone also showed protective effects. Combined use of pentobarbital and hypothermia resulted in highly significant recovery of spinal cord function.
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Affiliation(s)
- S Kazama
- Department of Cardiothoracic Surgery, Kitasato University School of Medicine, Sagamihara, Japan.
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Mori K, Maeda T, Shiraishi Y, Kawai Y. Effects of hypothermia on blood flow and neural activity in rabbit spinal cord during postischemic reperfusion. THE JAPANESE JOURNAL OF PHYSIOLOGY 2001; 51:71-9. [PMID: 11281998 DOI: 10.2170/jjphysiol.51.71] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The effects of hypothermia on blood flow and neural activity were investigated in rabbit spinal cord during the acute phase of ischemia/reperfusion. Rabbits were exposed to ischemia for 10 or 40 min by occluding the abdominal aorta, using a balloon catheter. The body temperature was maintained either at 38 degrees C (normothermia) or 34 degrees C (hypothermia). Hyperperfusion was observed within 10 min after the cessation of ischemia in all rabbits exposed to ischemia. The magnitude of hyperperfusion in spinal cord blood flow (SCBF) was not significantly different between the 10 and 40 min ischemia rabbits, but the time for 50% recovery from the hyperperfusion was longer in the 40 min ischemia group (26.1 +/- 2.5 min) than in the 10 min group (15.1 +/- 2.1 min). The amplitude of evoked spinal cord potential decreased during ischemia and recovered to the baseline level during 8 h of reperfusion in the 10 min ischemia group. However, in the 40 min ischemia group, the amplitude was 40 +/- 8% of the baseline value after 8 h of reperfusion. Hypothermia prevented the delay of recovery from hyperperfusion and the reduction of evoked spinal cord potential. These results suggest that hypothermia plays a beneficial role in protecting tissue injury in the acute phase of ischemia/reperfusion in the spinal cord by shortening the time for recovery from postischemic hyperperfusion.
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Affiliation(s)
- K Mori
- Department of Physiology, Faculty of Medicine, Tottori University, Yonago, 683-8503 Japan
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de Haan P, Kalkman CJ, Jacobs MJ. Pharmacologic neuroprotection in experimental spinal cord ischemia: a systematic review. J Neurosurg Anesthesiol 2001; 13:3-12. [PMID: 11145475 DOI: 10.1097/00008506-200101000-00002] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Various surgical procedures may cause temporary interruption of spinal cord blood supply and may result in irreversible ischemic injury and neurological deficits. The cascade of events that leads to neuronal death following ischemia may be amenable to pharmacological manipulations that aim to increase the tolerable duration of ischemia. Many agents have been evaluated in experimental spinal cord ischemia (SCI). In order to investigate whether an agent is available that justifies clinical evaluation, the literature on pharmacological neuroprotection in experimental SCI was systematically reviewed to assess the neuroprotective efficacy of the various agents. In addition, the strength of the evidence for neuroprotection was investigated by analyzing the methodology. The authors used a systematic review to conduct this evaluation. The included studies were analyzed for neuroprotection and methodology. In order to be able to compare the various agents for neuroprotective efficacy, relative risks and confidence intervals were calculated from the data in the results sections. A total of 103 studies were included. Seventy-nine different agents were tested. Only 14 of the agents tested did not afford protection at all. A large variation was observed in the experimental models to produce SCI. This variation limited comparison of the individual agents. In 48 studies involving 31 single agents, the relative risks and confidence intervals could be calculated. An analysis of the methodology revealed poor temperature management and lack of statistical power in the majority of the 103 studies. The results suggest that numerous agents may protect the spinal cord from transient ischemia. However, poor temperature management and lack of statistical power severely weakened the evidence. Consequently, clinical evaluation of pharmacological neuroprotection in surgical procedures that carry a risk of ischemic spinal cord damage is not justified on the basis of this study.
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Affiliation(s)
- P de Haan
- Department of Anesthesiology, Academic Hospital, University of Amsterdam, The Netherlands
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Westermaier T, Zausinger S, Baethmann A, Steiger HJ, Schmid-Elsaesser R. No additional neuroprotection provided by barbiturate-induced burst suppression under mild hypothermic conditions in rats subjected to reversible focal ischemia. J Neurosurg 2000; 93:835-44. [PMID: 11059666 DOI: 10.3171/jns.2000.93.5.0835] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Mild-to-moderate hypothermia is increasingly used for neuroprotection in humans. However, it is unknown whether administration of barbiturate medications in burst-suppressive doses-the gold standard of neuroprotection during neurovascular procedures-provides an additional protective effect under hypothermic conditions. The authors conducted the present study to answer this question. METHODS Thirty-two Sprague-Dawley rats were subjected to 90 minutes of middle cerebral artery occlusion and randomly assigned to one of four treatment groups: 1) normothermic controls; 2) methohexital treatment (burst suppression); 3) induction of mild hypothermia (33 degrees C); and 4) induction of mild hypothermia plus methohexital treatment (burst suppression). Local cerebral blood flow was continuously monitored using bilateral laser Doppler flowmetry and electroencephalography. Functional deficits were quantified and recorded during daily neurological examinations. Infarct volumes were assessed histologically after 7 days. Methohexital treatment, mild hypothermia, and mild hypothermia plus methohexital treatment reduced infarct volumes by 32%, 71%, and 66%, respectively, compared with normothermic controls. Furthermore, mild hypothermia therapy provided the best functional outcome, which was not improved by additional barbiturate therapy. CONCLUSIONS The results of this study indicate that barbiturate-induced burst suppression is not required to achieve maximum neuroprotection under mild hypothermic conditions. The magnitude of protection afforded by barbiturates alone appears to be modest compared with that provided by mild hypothermia.
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Affiliation(s)
- T Westermaier
- Department of Neurosurgery and Institute for Surgical Research, Klinikum Grosshadern, Ludwig Maximilians University, Munich, Germany
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Dimar JR, Shields CB, Zhang YP, Burke DA, Raque GH, Glassman SD. The role of directly applied hypothermia in spinal cord injury. Spine (Phila Pa 1976) 2000; 25:2294-302. [PMID: 10984780 DOI: 10.1097/00007632-200009150-00006] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN The effect of intense local hypothermia was evaluated in a precision model of spinal canal narrowing and spinal cord injury in rats. The spinal cord injury was cooled with a custom cooling well used over the epidural surface. Basso, Beattie, and Bresnahan (BBB) motor scores and transcranial magnetic motor-evoked potential (tcMMEP) responses were used after injury to accurately evaluate neurologic recovery. OBJECTIVE This study was undertaken to determine whether the prognosis for neurologic recovery in a standardized rat spinal cord injury model is altered by the direct application of precisely controlled hypothermia to the area of injury. SUMMARY OF BACKGROUND DATA The role of hypothermia in the treatment of spinal cord injuries with neurologic deficits remains undefined. Hypothermia may decrease an area of spinal cord injury and limit secondary damage, therefore improving neurologic recovery. However, it has been difficult to consistently apply localized cooling to an area of spinal cord injury, and the use of systemic hypothermia is fraught with complications. This fact, along with the unavailability of a precise spinal cord injury model, has resulted in inconsistent results, both clinically and in the laboratory. In a rat model of spinal cord injury, 37 C and 19 C temperatures were used to study the role of hypothermia on neurologic recovery. METHODS Male Spraque-Dawley rats (n = 52; weight, 277.7 g) were anesthetized with pentobarbital and subjected to laminectomy at T10. The rats were divided into three groups: 1) placement of a 50% spacer in the epidural space (16 rats), 2) severe (25 g/cm) spinal cord injury (16 rats), 3) 50% spacer in combination with spinal cord injury (16 rats). Eight rats in each group were tested at two temperatures: normothermic (37 C) and hypothermic (19 C). With the use of a specially designed hypothermic pool placed directly over the spinal cord for 2 hours, epidural heating to 37 C, and epidural cooling to 19 C was accomplished. Simultaneous measurements of spinal cord and body temperatures were performed. The rats underwent behavior testing using the BBB motor scores and serial tcMMEPs for 5 weeks. Statistical methods consisted of Student's t tests, one-way analysis of variance, Tukey post hoc t tests and chi2 tests. RESULTS There was a significant improvement in motor scores in rats subjected to hypothermia compared with those that were normothermic after insertion of a 50% spacer. This improvement was observed during the 5-week duration of follow-up. In the severe spinal cord injury group and the spinal cord injury-spacer groups, no significant improvement in motor scores were obtained when the spinal cord was exposed to hypothermia. CONCLUSION The results demonstrate that there is a statistically significant (P < 0.05) improvement in neurologic function in rats subjected to hypothermia (19 C) after insertion of a spacer that induced an ischemic spinal cord injury. This indicates that directly applied hypothermia may be beneficial in preventing injury secondary to ischemic cellular damage. The data demonstrated minimal therapeutic benefit of hypothermia (19 C) after a severe spinal cord injury.
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Affiliation(s)
- J R Dimar
- Departments of Orthopaedic Surgery and Neurological Surgery, University of Louisville, and the Kenton D. Leatherman Spine Center, Louisville, Kentucky 40202, USA.
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Lang-Lazdunski L, Heurteaux C, Dupont H, Widmann C, Lazdunski M. Prevention of ischemic spinal cord injury: comparative effects of magnesium sulfate and riluzole. J Vasc Surg 2000; 32:179-89. [PMID: 10876221 DOI: 10.1067/mva.2000.105960] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Excitotoxic mechanisms have been implicated in the pathophysiology of spinal cord ischemic injury induced by aortic cross-clamping. We investigated the effects of the anti-excitotoxic drugs magnesium sulfate (MgSO(4)) and riluzole in a rabbit model of spinal cord ischemia. METHOD The infrarenal aorta of New Zealand albino white rabbits (n = 68) was occluded for 40 minutes. Experimental groups included: a control group, which received only vehicle (n = 17); group A (n = 17), which received riluzole (8 mg/kg) before clamping; group B (n = 17), which received MgSO(4) (100 mg/kg) before clamping; and group C (n = 17), which received riluzole (8 mg/kg) and MgSO(4) (100 mg/kg) before clamping. Five additional rabbits had the same operation, but did not undergo aortic clamping (sham operation). The neurological status of the rabbits was assessed at 24 hours, 48 hours, and then daily for as long as 120 hours by using a modified Tarlov scale. The rabbits were killed at 24 hours (n = 3 per group), 48 hours (n = 4 per group), and 120 hours (n = 10 per group) postoperatively. Spinal cords were harvested for histopathologic and immunohistochemistry examinations for microtubule-associated protein-2 (MAP-2), a cytoskeletal protein specific from neurons. RESULTS No major adverse effect was observed with either riluzole or MgSO(4). All control rabbits became severely paraplegic. All riluzole-treated and MgSO(4)-treated animals had a better neurological status than control animals. Typical morphological changes characteristic of neuronal necrosis in the gray matter of control animals was demonstrated by means of the histopathological examination, whereas riluzole or magnesium prevented or attenuated necrotic phenomenons. Moreover, MAP-2 immunoreactivity was completely lost in control rabbits, whereas it was preserved, either completely or partially, in rabbits treated with riluzole or magnesium. Riluzole was more effective than MgSO(4) in preventing paraplegia caused by motor neuron injury (P <.01 ). Riluzole and MgSO(4) had no additive neuroprotective effect. CONCLUSION These results demonstrate that riluzole and, to a lesser extent, MgSO(4) may afford significant spinal cord protection in a setting of severe ischemia and may, therefore, be considered for clinical use during "high-risk" operations on the thoracic and thoracoabdominal aorta.
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Affiliation(s)
- L Lang-Lazdunski
- Departments of Cardiovascular Surgery and Anesthesiology, Hopital Bichat and Xavier Bichat Medical University, Paris, France
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Yu CG, Jimenez O, Marcillo AE, Weider B, Bangerter K, Dietrich WD, Castro S, Yezierski RP. Beneficial effects of modest systemic hypothermia on locomotor function and histopathological damage following contusion-induced spinal cord injury in rats. J Neurosurg 2000; 93:85-93. [PMID: 10879763 DOI: 10.3171/spi.2000.93.1.0085] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Local spinal cord cooling (LSCC) is associated with beneficial effects when applied following ischemic or traumatic spinal cord injury (SCI). However, the clinical application of LSCC is associated with many technical difficulties such as the requirement of special cooling devices, emergency surgery, and complicated postoperative management. If hypothermia is to be considered for future application in the treatment of SCI, alternative approaches must be developed. The objectives of the present study were to evaluate 1) the relationship between systemic and epidural temperature after SCI; 2) the effects of modest systemic hypothermia on histopathological damage at 7 and 44 days post-SCI; and 3) the effects of modest systemic hypothermia on locomotor outcome at 44 days post-SCI. METHODS A spinal cord contusion (12.5 mm at T-10) was produced in adult rats that had been randomly divided into two groups. Group 1 rats (seven in Experiment 1; 12 in Experiment 2) received hypothermic treatment (epidural temperature 32-33 degrees C) 30 minutes postinjury for 4 hours; Group 2 rats (nine in Experiment 1; eight in Experiment 2) received normothermic treatment (epidural temperature 37 degrees C) 30 minutes postinjury for 4 hours. Blood pressure, blood gas levels, and temperatures (epidural and rectal) were monitored throughout the 4-hour treatment period. Twice weekly assessment of locomotor function was performed over a 6-week survival period by using the Basso-Beattie-Bresnahan locomotor rating scale. Seven (Experiment 1) and 44 (Experiment 2) days after injury, animals were killed, perfused, and their spinal cords were serially sectioned. The area of tissue damage was quantitatively analyzed from 16 longitudinal sections selected from the central core of the spinal cord. CONCLUSIONS The results showed that 1) modest changes in the epidural temperature of the spinal cord can be produced using systemic hypothermia; 2) modest systemic hypothermia (32-33 degrees C) significantly protects against locomotor deficits following traumatic SCI; and 3) modest systemic hypothermia (32-33 degrees C) reduces the area of tissue damage at both 7 and 44 days postinjury. Although additional research is needed to study the therapeutic window and long-term benefits of systemic hypothermia, these data support the possible use of modest systemic hypothermia in the treatment of acute SCI.
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Affiliation(s)
- C G Yu
- The Miami Project, and Department of Neurological Surgery, University of Miami, Florida, USA
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Chatzipanteli K, Yanagawa Y, Marcillo AE, Kraydieh S, Yezierski RP, Dietrich WD. Posttraumatic hypothermia reduces polymorphonuclear leukocyte accumulation following spinal cord injury in rats. J Neurotrauma 2000; 17:321-32. [PMID: 10776915 DOI: 10.1089/neu.2000.17.321] [Citation(s) in RCA: 112] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The present study addresses the effects of moderate posttraumatic hypothermia (32 degrees C) on the temporal and regional profile of polymorphonuclear leukocyte (PMNL) accumulation after traumatic spinal cord injury (SCI). We hypothesized that posttraumatic hypothermia would reduce the degree of inflammation by reducing PMNL infiltration. Rats underwent moderate spinal cord injury at T10 using the NYU impactor device. In the first study, the temporal profile of myeloperoxidase (MPO) activity (a marker of neutrophil accumulation) under normothermic (37 degrees C) conditions was determined. The animals were allowed to survive for 3 or 24 h, or 3 or 7 days after SCI. Spinal cords were dissected into five segments rostral and caudal to the injury site. Additional animals were studied for the immunocytochemical visualization of MPO. In the second study, rats were sacrificed at 24 h after a monitoring period of normothermia (36.5 degrees C/3 h) or hypothermia (32.4 degrees C/3 h) with their controls. In the time course studies, MPO enzymatic activity was significantly increased at 3 and 24 h within the traumatized T10 segment compared to controls. MPO activity was also increased at 3 h within the rostral T8 and T9 segments and caudal T11 and T12 segments compared to controls. At 24 h after trauma, MPO activity remained elevated within both the rostral and caudal segments compared to control. By 3 days, the levels of MPO activity were reduced compared to the 24-h values but remained significantly different from control. Neutrophils that exhibited MPO immunoreactivity were seen at 6 and 24 h, with a higher number at 3 days. PMNLs were located within the white and gray matter of the lesion and both rostral and caudal to the injury site. Posttraumatic hypothermia reduced MPO activity at 24 h in the injured spinal cord segment, compared to normothermic values. The results of this study indicate that a potential mechanism by which hypothermia improves outcome following SCI is by attenuating posttraumatic inflammation.
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Affiliation(s)
- K Chatzipanteli
- Department of Neurological Surgery, University of Miami School of Medicine, Florida 33136, USA
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Abstract
Brain and spinal cord white matter are vulnerable to the effects of ischaemia. Reduction of the energy supply leads to a cascade of events including depolarization, influx of Na(+) and the subsequent reverse operation of the membrane protein the Na(+)/Ca(2+) exchanger which ultimately terminates in intracellular Ca(2+) overload and irreversible axonal injury. Various points along the white matter damage cascade could be specifically targeted as a potential means of inhibiting the development of axonal irreversible injury.
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Affiliation(s)
- M A Petty
- CNS Research, Hoechst Marion Roussel, Bridgewater, NJ 08807, USA.
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Follis FM, Blisard KS, Varvitsiotis PS, Pett SB, Temes RT, Wernly JA. Selective protection of gray and white matter during spinal cord ischemic injury. Ann Thorac Surg 1999; 67:1362-9. [PMID: 10355413 DOI: 10.1016/s0003-4975(99)00257-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ischemic injury in the gray matter is associated with excitatory amino acid neurotransmitters (EAA) release, and in the white matter is associated with intracellular sodium accumulation. We investigated the protective effect during spinal ischemia of the EAA antagonist, 2-carboxypiperazinyl-propylphosphonic acid (CPP), and the sodium channel blocker (2,6-dimethylphenylcarbamoylmethyl) triethylammonium bromide (QX). METHODS Sprague-Dawley rats were randomized in four groups, received intrathecally 10 microL of saline, CPP, QX, or QX/CPP, and underwent balloon occlusion of the aorta. Proximal pressure was lowered by exsanguination. In the acute protocol, 28 rats were used to calculate the length of occlusion, resulting in paraplegia in 50% of animals (P50). In the chronic study, 60 rats underwent 11' occlusion. The chronic animals were scored daily for 28 days and submitted to cord histology. RESULTS The P50 of QX (11'22") and QX/CPP (11'54") were longer than saline (10'39"), suggesting a beneficial effect. Neurologic scores of all treatment groups (p = 0.0001) and histologic scores of CPP (p = 0.003) and QX/CPP (p = 0.002) were better than saline. CONCLUSIONS Protection of spinal cord during ischemia can be achieved with intrathecal administration of selective agents directed to the gray and white matter.
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Affiliation(s)
- F M Follis
- Department of Cardiothoracic Surgery, University of New Mexico Health Sciences Center, Albuquerque 87131, USA.
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Guluma KZ, Saatman KE, Brown A, Raghupathi R, McIntosh TK. Sequential pharmacotherapy with magnesium chloride and basic fibroblast growth factor after fluid percussion brain injury results in less neuromotor efficacy than that achieved with magnesium alone. J Neurotrauma 1999; 16:311-21. [PMID: 10225217 DOI: 10.1089/neu.1999.16.311] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Combinational pharmacotherapy with individually efficacious agents is a potential strategy for the treatment of traumatic central nervous system (CNS) injury. Basic fibroblast growth factor (bFGF) has been shown to be neuroprotective against excitotoxic, ischemic, and traumatic injury to the CNS, while acute posttraumatic treatment with magnesium (Mg2+) has been shown to decrease the motor and cognitive deficits following experimental brain injury. In this study, bFGF and Mg2+ were evaluated separately and in combination to assess their potential additive effects on posttraumatic neurological recovery and histological cell loss (lesion volume). Twenty minutes after fluid percussion (FP) brain injury of moderate severity (2.2-2.4 atm), anesthetized rats received a 15-min intravenous infusion of either 125 mumol of MgCl2 or vehicle, followed 5 min later by a 24-h constant intravenous infusion of either bFGF (16 micrograms/h) or vehicle. Injured animals had a significant motor deficit when compared to sham (uninjured) animals at both 48 h and 7 days postinjury. At 48 h postinjury, there were no significant differences among injured animals when compared by treatment. By 7 days postinjury, injured animals treated with MgCl2 alone displayed significantly improved motor function when compared to brain-injured, vehicle-treated animals (p < 0.05). Animals treated with either bFGF alone or a combination of MgCl2 and bFGF displayed no significant neurological improvement relative to vehicle-treated injured animals at 7 days. No effect of any drug treatment of combination was observed on the extent of the postinjury lesion volume in the injured cortex. These results suggest that caution must be exercised when combining "cocktails" of potentially neuroprotective compounds in the setting of traumatic brain injury.
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Affiliation(s)
- K Z Guluma
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, USA
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Güney O, Acar O, Demir O, Ustün ME, Kocaoğullar Y. Somatosensory spinal cord evoked potentials in the evaluation of the effect of dexamethasone in experimental spinal cord injury. Neurosurg Rev 1999; 21:265-9. [PMID: 10068188 DOI: 10.1007/bf01105783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We studied the effects of high-dose dexamethasone on amplitude and latency values of spinal cord evoked potentials. Thirty-three rabbits were divided into three equal groups. The first group served as the control group, the others received high-dose (2.5 mg/kg) dexamenthasone, the second group 1 hour prior to and the third group immediately after the induction of a spinal cord trauma in segment T12. The spinal cord evoked potentials were recorded epidurally from T12 segment 5 min before and 5, 30, 60, 90, 120 and 150 min after trauma. Pretreatment with dexamethasone (group II) prevented the latency delay, and later treatment with dexemethasone (group III) prevented the latency delay partially. Our results suggest that when dexamethasone is given prophylactically it prevents latency alteration, while treatment with dexamethasone after lesioning prevents latency alteration partially. From our results we conclude that pretreatment with dexamethasone may involve different mechanisms than were activated in the posttreatment group.
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Affiliation(s)
- O Güney
- Department of Neurosurgery, Selçuk University Medical School, Konya, Turkey
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Heath DL, Vink R. Improved motor outcome in response to magnesium therapy received up to 24 hours after traumatic diffuse axonal brain injury in rats. J Neurosurg 1999; 90:504-9. [PMID: 10067920 DOI: 10.3171/jns.1999.90.3.0504] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The goal of this study was to establish the therapeutic window during which delayed therapy with MgSO4 improves neurological motor outcome in rats that have suffered severe traumatic axonal brain injury. METHODS Severe brain injury was induced in male Sprague-Dawley rats by using the impact-acceleration model of severe traumatic diffuse axonal brain injury. Injured animals were subsequently treated with MgSO4 (750 micromol/kg) infused intramuscularly at 30 minutes or at 8, 12, or 24 hours after trauma and were tested for neurological motor outcome during the following week by using the rotarod test. Injured untreated (control) animals demonstrated highly significant (p < 0.001) neurological motor deficits that were sustained over the 1-week assessment period. Animals treated with MgSO4 at 30 minutes or at 8 or 12 hours postinjury demonstrated significantly improved motor outcomes compared with untreated control animals at all time points (0.001 < p < 0.05). Animals treated with MgSO4 at 24 hours had motor scores that were similar to those of untreated control animals early in the week, but demonstrated a significantly more rapid recovery in function and, by the end of the assessment period, they demonstrated significantly improved motor scores (p < 0.01). Repeated administration of MgSO4 over the 1-week observation period did not further improve outcome. CONCLUSIONS The present results demonstrate that Mg++ plays a neuroprotective role following severe diffuse traumatic axonal brain injury. Moreover, Mg++ therapy significantly improved motor outcome when administered up to 24 hours after injury, with early treatments providing the most significant benefit. Repeated administration beyond 24 hours postinjury did not provide additional neuroprotection.
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Affiliation(s)
- D L Heath
- Department of Physiology and Pharmacology, James Cook University, Townsville, Queensland, Australia
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Alessandri B, Bullock R. Glutamate and its receptors in the pathophysiology of brain and spinal cord injuries. PROGRESS IN BRAIN RESEARCH 1999; 116:303-30. [PMID: 9932385 DOI: 10.1016/s0079-6123(08)60445-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
- B Alessandri
- Medical College of Virginia, Department of Neurosurgery, Richmond 23298, USA.
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Schmid-Elsaesser R, Zausinger S, Hungerhuber E, Baethmann A, Reulen HJ. Neuroprotective effects of combination therapy with tirilazad and magnesium in rats subjected to reversible focal cerebral ischemia. Neurosurgery 1999; 44:163-71; discussion 171-2. [PMID: 9894977 DOI: 10.1097/00006123-199901000-00100] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Cell death after cerebral ischemia is mediated by release of excitatory amino acids, calcium influx into cells, and generation of free radicals. We examined the hypothesis that concurrent administration of tirilazad, a well-known antioxidant, and magnesium, an antagonist of calcium and excitatory amino acids, would result in a synergistic neuroprotective effect. METHODS Sprague-Dawley rats were subjected to transient middle cerebral artery occlusion and assigned to one of four treatment arms (n = 10 in each): 1) vehicle, 2) tirilazad, 3) MgCl2, or 4) tirilazad and MgCl2. Cortical blood flow was recorded using laser Doppler flowmetry. Functional deficits were quantified by performing daily neurological examinations. Infarct volume was assessed after 7 days. RESULTS There was no difference in cortical blood flow among groups. Animals that received tirilazad or MgCl2 monotherapy had significantly better neurological function compared with control animals only on postoperative Days 3 and 4, whereas animals treated with both drugs had significantly better neurological function than did control animals from postoperative Days 2 through 7. Magnesium reduced total infarct volume by 25% (nonsignificant), tirilazad by 48% (P<0.05), and combination therapy by 59% (P<0.05) compared with control data. CONCLUSION Combined therapy with antagonists of excitatory amino acids and free radicals provides better neuroprotection from the effects of transient focal ischemia than does therapy with either antagonist alone. In contrast to many experimental agents, tirilazad and magnesium offer the advantage of being licensed for clinical use. This drug combination could be of great benefit when administered before temporary artery occlusion in patients undergoing cerebrovascular surgery.
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Affiliation(s)
- R Schmid-Elsaesser
- Department of Neurosurgery, Ludwig-Maximilians-Universität, Klinikum Grosshadern, Munich, Germany
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Westergren H, Holtz A, Farooque M, Yu WR, Olsson Y. Systemic hypothermia after spinal cord compression injury in the rat: does recorded temperature in accessible organs reflect the intramedullary temperature in the spinal cord? J Neurotrauma 1998; 15:943-54. [PMID: 9840767 DOI: 10.1089/neu.1998.15.943] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This article addresses one basic issue regarding the use of systemic hypothermia in the acute management of spinal cord injury, namely, how to interpret temperature recordings in accessible organs such as the rectum or esophagus with reference to the spinal cord temperature. Thirty-six rats, divided into six groups, were randomized to laminectomy or to severe spinal cord compression trauma, and were further randomized to either a cooling/rewarming procedure or continuous normothermia (esophageal temperature 38 degrees C) for 90 min. The first procedure comprised normothermia during the surgical procedure, followed by lowering of the esophageal temperature from 38 degrees C to 30 degrees C (the hypothermic level), a 20-min steady-state period at 30 degrees C, rewarming to 38 degrees C, and finally a 20-min steady-state period at 38 degrees C. The esophageal, rectal, and epidural temperatures were recorded in all animals. The intramedullary temperature was also recorded invasively in four of the six groups. We conclude that the esophageal temperature is safe and easy to record and, in our setting, reflects the epidural temperature. The differences registrated may reflect a true deviation of the intramedullary temperature due to initial environmental exposure and secondary injury processes. Our results indicate that the esophageal temperature exceeds the intramedullary temperature during the initial recording and final steady state following rewarming, but not during the most crucial part of the experiment, the hypothermic period. The core temperature measured in the esophagus can therefore be used to evaluate the intramedullary temperature during alterations of the systemic temperature and during hypothermic periods.
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Affiliation(s)
- H Westergren
- Department of Neurosurgery, University Hospital, Uppsala, Sweden
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Yamada T, Morimoto T, Nakase H, Hirabayashi H, Hiramatsu K, Sakaki T. Spinal cord blood flow and pathophysiological changes after transient spinal cord ischemia in cats. Neurosurgery 1998; 42:626-34. [PMID: 9526997 DOI: 10.1097/00006123-199803000-00033] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The goal was to study the hemodynamics and regional pathophysiological changes in the spinal cord after transient vascular occlusion in cats. METHODS We measured spinal cord blood flow (SCBF) continuously in the lumbar region with a laser-doppler flowmeter, before, during, and after spinal cord ischemia induced by balloon occlusion of the thoracic aorta, in 24 cats (divided into three groups) and simultaneously recorded the evoked spinal cord potentials (ESPs). In each group (n = 8), 10-, 20-, and 30-minute ischemic loading was performed. All animals were evaluated neurologically 36 hours later, and then their spinal cords were examined histologically. RESULTS The amplitude of ESPs decreased 10 minutes and disappeared 20 minutes after occlusion. SCBF increased to as much as 2 times the control values after reperfusion and decreased gradually in all groups. Then, in all animals in the 10-minute group and six animals in the 20-minute group, SCBF returned to the control values, which were subsequently maintained throughout the experiment, and ESPs returned to normal patterns within 1 hour. For all animals in the 30-minute group and two in the 20-minute group, hypoperfusion after recirculation, irreversible amplitude changes in ESPs, postischemic paraparesis, and pathological ischemic changes in the lower thoracic and lumbar spinal segments were recognized. CONCLUSION Our results showed that > 20-minute occlusion of the thoracic aorta in cats resulted in irreversible spinal perfusion disorders and that the monitoring of SCBF and ESPs could be useful for predicting potential neurological deficits. Furthermore, postischemic hypoperfusion may have an important role in the development of secondary spinal cord ischemia, resulting in severe neurological dysfunction. This observation suggested the possibility of therapeutic modification of the secondary processes inducing hypoperfusion after spinal ischemia.
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Affiliation(s)
- T Yamada
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
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