Cerebrospinal fluid drainage and blood pressure elevation to treat acute spinal cord infarct

Pharmacologic and Acute Management of Spinal Cord Injury in Adults and Children

Purpose of Review

This review provides guidance for acute spinal cord injury (SCI) management through an analytical assessment of the most recent evidence on therapies available for treating SCI, including newer therapies under investigation. We present an approach to the SCI patient starting at presentation to acute rehabilitation and prognostication, with additional emphasis on the pediatric population when evidence is available.

Recent Findings

Further studies since the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) demonstrated a potential functional outcome benefit with ultra-early surgical intervention ≤ 8 h post-SCI. Subsequent analysis of the National Acute Spinal Cord Injury Study (NASCIS) II and NASCIS III trials have demonstrated potentially serious complications from intravenous methylprednisolone with limited benefit. Newer therapies actively being studied have demonstrated limited or no benefit in preclinical and clinical trials with insufficient evidence to support use in acute SCI treatment.

Summary

Care for SCI patients requires a multi-disciplinary team. Immediate evaluation and management are focused on preventing additional injury and restoring perfusion to the affected cord. Rapid assessment and intervention involve focused neurological examination, targeted imaging, and surgical intervention when indicated. There are currently no evidence-based recommendations for pathomechanistically targeted therapies.

Management of Acute Traumatic Spinal Cord Injury: A Review of the Literature

Traumatic spinal cord injury (TSCI) is a debilitating disease that poses significant functional and economic burden on both the individual and societal levels. Prognosis is dependent on the extent of the spinal injury and the severity of neurological dysfunction. If not treated rapidly, patients with TSCI can suffer further secondary damage and experience escalating disability and complications. It is important to quickly assess the patient to identify the location and severity of injury to make a decision to pursue a surgical and/or conservative management. However, there are many conditions that factor into the management of TSCI patients, ranging from the initial presentation of the patient to long-term care for optimal recovery. Here, we provide a comprehensive review of the etiologies of spinal cord injury and the complications that may arise, and present an algorithm to aid in the management of TSCI.

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

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

Evaluation and Management of Acute Myelopathy

Acute myelopathies are spinal cord disorders characterized by a rapidly progressive course reaching nadir within hours to a few weeks that may result in severe disability. The multitude of underlying etiologies, complexities in confirming the diagnosis, and often unforgiving nature of spinal cord damage have always represented a challenge. Moreover, certain slowly progressive myelopathies may present acutely or show abrupt worsening in specific settings and thus further complicate the diagnostic workup. Awareness of the clinical and magnetic resonance imaging characteristics of different myelopathies and the specific settings where they occur is fundamental for a correct diagnosis. Neuroimaging helps distinguish compressive etiologies that may require urgent surgery from intrinsic etiologies that generally require medical treatment. Differentiation between various myelopathies is essential to establish timely and appropriate treatment and avoid harm from unnecessary procedures. This article reviews the contemporary spectrum of acute myelopathy etiologies and provides guidance for diagnosis and management.

Current practices and goals for mean arterial pressure and spinal cord perfusion pressure in acute traumatic spinal cord injury: Defining the gaps in knowledge

Context: The mainstay of treatment for acute traumatic spinal cord injury (SCI) is to artificially elevate the patient's mean arterial pressure (MAP) to >85 mmHg to increase blood flow to the injured spinal cord for 7 days. However, the literature supporting these recommendations are only Class III evidence. In fact, the critical time window in which to elevate MAP after SCI and the optimal vasopressor to use are largely unknown, as is whether cerebrospinal fluid diversion has a role, and this leads to variability among practitioners. Also undefined is whether manipulating these parameters improves neurological outcome.Objective: Our goal is to better delineate current clinical practice and identify gaps in knowledge surrounding the care of patients with traumatic SCI.Methods: We undertook a systematic review of the current literature identified from PubMed on MAP elevation and spinal cord parenchymal pressure in acute SCI.Results: The 8 articles (6 human; 2 porcine) that met our inclusion criteria were all published within the last 6 years. Four were prospective, 1 was retrospective, and 3 were review articles. Only one study was randomized. All of these studies involved small sample sizes and varying lengths of MAP elevation. Choice of vasopressor was variable as well.Conclusions: From our literature review, we posit that norepinephrine may be the vasopressor of choice, that spinal parenchymal pressure monitors can be safely placed at the injury site, and that the combination of MAP elevation and cerebrospinal fluid drainage may improve neurologic outcome more than either intervention alone.

Spinal Cord Infarction after Bronchial Artery Embolization for Hemoptysis: A Nationwide Observational Study in Japan

Background The most serious complication of bronchial artery embolization (BAE) for hemoptysis is spinal cord infarction. However, because it is rare, previous reports from single institutions have been insufficient to determine the actual prevalence of spinal cord infarction after BAE. Purpose To investigate the actual prevalence of spinal cord infarction as a complication of BAE using a nationally representative inpatient database. Materials and Methods This retrospective study was performed using data from the Japanese Diagnosis Procedure Combination database between July 2010 and March 2018. The authors identified patients who were diagnosed with hemoptysis and underwent BAE during hospitalization. The overall prevalence of spinal cord infarction after BAE was determined. The authors also compared the prevalence of spinal cord infarction using the Fisher exact test according to the embolic agent used for BAE: coils, gelatin sponge (GS) particles, and N-butyl-2-cyanoacrylate (NBCA). Results During the study period, 8563 patients (mean age ± standard deviation, 68 years ± 13; 5103 men) met the inclusion criteria. Among these 8563 patients, 1577 (18%), 6561 (77%), and 425 (5%) underwent BAE with coils, GS particles, and NBCA, respectively. The overall prevalence of spinal cord infarction as a complication of BAE was 0.19% (16 of 8563 patients). The prevalence of spinal cord infarction after BAE with coils, GS particles, and NBCA was 0.06% (one of 1577 patients), 0.18% (12 of 6561 patients), and 0.71% (three of 425 patients), respectively (P = .04). Conclusion With use of a nationwide real-world inpatient database, the results of this study demonstrated that the actual prevalence of spinal cord infarction as a complication of bronchial artery embolization (BAE) for hemoptysis was 0.19%. Patients who underwent BAE with coils had a lower prevalence of spinal cord infarction than patients who underwent BAE with gelatin sponge particles or N-butyl-2-cyanoacrylate. © RSNA, 2021.