Role of degenerated neuron density of dorsal root ganglion on anterior spinal artery vasospasm in subarachnoid hemorrhage: experimental study

BACKGROUND

The spinal arteries are innervated by several systems that contribute to the control of spinal cord blood flow. The sensory fibers of upper cervical nerves have vasodilatatory effect on the anterior spinal arteries (ASA). Subarachnoid hemorrhage (SAH) causes severe vasospasm by various neurochemical mechanisms. We examined whether there is a relationship between the neuron density of the C3 dorsal root ganglion and the severity of ASA vasospasm in SAH.

METHODS

This study was conducted on 20 rabbits. Four of them were used as baseline group. Experimental SAH has been applied to all of 16 animals by injecting homologous blood into cisterna magna. After 20 days of injection, ASA and C3 dorsal root ganglia (C3DRG) were examined histopathologically. ASA volume values and normal and degenerated neuron densities of C3DRG were estimated stereologically and the results were analyzed statistically.

RESULTS

The mean ASA volume was 1.050±0.450 mm³, [corrected] and the mean neuronal density of C3DRG was 10,500 ± 850 in all animals. The mean volume value of ASA was 0.970±0.150 [corrected] mm³, and the normal neuron density of C3DRG fell to 8,600 ± 400/mm³ in slight vasospasm group. In severe vasospasm-developed animals, mean volume value of ASA was 0.540±0.90 [corrected]mm³ and the normal neuron density of C3DRG fell to 5,500 ± 360/mm³. An inverse relationship between the degenerated neuronal density of the C3DRG and ASA volume values may indicate the severity of ASA vasospasm.

CONCLUSION

The neuron density of C3DRG may be an important factor on the regulation of ASA volume values and the continuation of spinal cord blood flow. Low neuron density of C3DRG may be considered as an important factor in the pathogenesis of severe ASA vasospasm in SAH.

Anterior spinal artery syndrome after elective coronary artery bypass grafting

A 65-year-old patient with ischemic heart disease and hypertensive nephropathy had paraplegia develop after elective coronary artery revascularization caused by anterior spinal infarction. Spinal complications are rare after coronary artery bypass grafting. The possible mechanisms of spinal cord injury are discussed, and the relevant literature is reviewed.

Delayed anterior spinal artery syndrome following posterior scoliosis correction

The authors report two cases of delayed post-operative anterior spinal artery syndrome (ASAS) following posterior correction with Cotrel Dubousset (CD) instrumentation for adolescent idiopathic scoliosis. Sensory pathways were continuously monitored from skin incision to awakening. In both cases intraoperative SEPs were normal and the wake-up test revealed no neurological deficit. Both patients were presented with incomplete paraplegia (no sensory impairment) three and ten hours after surgery. Without delay, both patients underwent revision surgery, and the CD instrumentation was removed. Immediately after surgery, both patients' motor power in their lower extremities improved rapidly. In cases with delayed ASAS after posterior scoliosis correction, the removal of the instrumentation system was shown to be sufficient to regain full motor recovery caudal to the level of impairment.

Anterior spinal artery syndrome in an adolescent with protein S deficiency

The diagnosis of anterior spinal artery syndrome can be made with high accuracy by thorough clinical examination in combination with typical magnetic resonance imaging findings. Sudden onset of tetra- or paraparesis and dissociated sensory loss with bladder dysfunction are the leading clinical signs. We discuss clinical and radiologic findings in an adolescent presenting with anterior spinal artery syndrome. The laboratory results showed a hereditary protein S deficiency.

Anterior spinal artery syndrome after aortic surgery in a child

Anterior spinal artery syndrome is rare in children. In adults, where it is observed most frequently after resection of thoracoabdominal aortic aneurysms, spinal magnetic resonance imaging is considered the first-line investigation to confirm the clinical diagnosis. A 3-year-old male who presented with this syndrome after palliative cardiac surgery for a complex cardiac malformation associated with aortic coarctation is presented. Clinical diagnosis of anterior horn cell impairment below the L2 level was confirmed by electromyography and F-wave studies. Sparing of dorsal sensory tracts was documented by normal somatosensory-evoked potentials, which confirmed the anterior localization of the lesion. Spinal magnetic resonance imaging performed on day 15 and day 105 after surgery was normal. Neurologic deficits, including flaccid paraplegia, remained stable except for the reappearance of patellar reflexes on day 83. Neurophysiologic conduction studies were consistent with lower motoneuron loss. In this patient, magnetic resonance imaging was less sensitive in demonstrating spinal cord lesion than clinical neurophysiology. Somatosensory-evoked potentials failed to detect the insult. Prevention may therefore require other neurophysiologic monitoring techniques.

Cruciate paralysis or man-in-the-barrel syndrome? Report of a case of brachial diplegia

A patient who developed isolated brachial diplegia following cardiac surgery is described. The underlying cerebral lesion could not be localized using magnetic resonance imaging (MRI). Evoked potentials disclosed normal findings, while pathological latencies were seen on cortical magnetic stimulation. Their marked improvement over the following year was accompanied by almost complete clinical recovery. The preserved arm reflexes, together with the observed slow firing motor units in electromyography argued against bilateral lesions of the brachial plexus. We attribute the observed diplegia to a medullary lesion at the level of the pyramidal decussation, presumably caused by an intraoperative embolic occlusion of the anterior spinal artery. Cruciate paralysis and man-in-barrel-syndrome (MIBS) both are terms used to describe brachial diplegia; cruciate paralysis when caused by medullary lesions, MIBS when caused either by supratentorial or by medullary lesions. Exclusive use of the term MIBS for bilateral frontal lobe lesions, as in the original description, would provide more clarity in terminology.

Complex arteriovenous fistulas at C1 causing hematomyelia through aneurysmal rupture of a feeder from the anterior spinal artery

A 64-year-old woman presented with left occipital headache and right dissociated sensory loss due to hematomyelia on the left ventral side of C1 caused by rupture of an aneurysm on one of the feeders extending from the anterior spinal artery to complex epidural or dural and intradural arteriovenous fistulas (AVFs). Branches from the left occipital and ascending pharyngeal arteries and those from the left C2 radicular, left posterior spinal and anterior spinal arteries formed these multiple shunts, linking with a common venous drain flowing into the right petrosal vein. Surgical interception of all the shunts was achieved, making it unnecessary to directly treat the aneurysm in the spinal cord. The feeders, aneurysm and AVFs were not visualized on postoperative angiography, and the patient returned to a normal working life.

Anterior spinal artery syndrome complicating aortic dissecting aneurysm: case report

Spinal Cord ischaemia is rare in the absence of trauma. We report a case of a 45 year old known hypertensive for six years, who presented with features of anterior spinal artery syndrome (ASAS) complicating acute dissection of the descending aorta. He developed sudden onset non-traumatic paraparesis, sphincteric dysfunction and dissociated anaesthesia with a sensory level at T6. This was preceded by a two weeks' history of severe, sharp, lancinating, tearing left parasternal chest pain radiating to the back. He was managed conservatively on pentazocine lactate (fortwin), calcium- and beta-blockers, steroids, anti-platelet and free-radical scavengers. On the 8th day of hospitalisation, he had a sudden abdominal distension, bled from the nose and mouth, went into hypovolaemic shock and died within a time frame of two minutes. He was presumed to have had a progression of the aortic dissection with subsequent rupture. Dissecting aortic aneurysm could run a benign asymptomatic or a lethal course and a high index of suspicion is necessary. The lack of exhaustive diagnostic investigative tools as well as surgical intervention in the management of this patient in a developing country was highlighted as was possible that the patient could have been mismanaged.

Ischemic spinal cord syndrome after transthoracic esophagectomy: two cases of a rare neurologic complication

Anterior spinal artery syndrome (ASAS) is a rare complication after surgery of the thoracic or abdominal aorta. The sulco commissuralis syndrome represents a partial or incomplete ASAS. We report two cases of ischemic spinal cord syndromes after transthoracic esophagectomy. This represents a prevalence of this syndrome of 0.2% in more than 1000 consecutive esophagectomies performed at our institution. Patient 1 developed an ASAS on the first day after esophagectomy. Patient 2 showed the pathognomonic clinical signs associated with sulco commissuralis syndrome after an asymptomatic window. In both patients, the extent of the neurologic symptoms initially improved but then remained unchanged for the rest of the follow-up of 9 and 12 months. Although the prognosis of neurologic syndromes resulting from spinal cord infarction is poor, preoperative tests to identify patients at risk appear not to be justified because of the very low incidence of these syndromes after esophagectomy and the poor sensitivity and specificity of currently available diagnostic modalities. However, the possibility of ischemic spinal cord syndrome should be kept in mind when patients present with neurologic symptoms after esophagectomy.

Anterior spinal artery syndrome after peripheral angiography of the lower limbs

STUDY DESIGN

A case report of temporary anterior spinal artery syndrome secondary to peripheral angiography of the lower limbs.

OBJECTIVES

To report a rare case of spinal cord ischemia following a straightforward peripheral angiography with femoral access.

SETTING

Istanbul, Turkey.

CASE REPORT

A 70-year-old patient with peripheral vascular disease developed temporary paraplegia after angiography caused by anterior spinal ischemia. His motor weakness improved gradually over a 2 month period.

CONCLUSION

Spinal complications are extremely rare after peripheral angiography. The possible mechanisms of spinal cord damage are discussed, and the relevant data regarding the etiology are reviewed.

Post-traumatic cervical kyphosis with surgical correction complicated by temporary anterior spinal artery syndrome

Post-traumatic undiagnosed disco-ligamentous and osseous lesions of the cervical spine may eventually result in irreducible extreme kyphosis. Correction of such consolidated deformities requires major surgery with a combined posterior and anterior approach, aiming to correct bony impingement on neural and vascular structures, reduce deformity and to attain circumferential instrumentation and fusion in physiological alignment. This can be achieved using either a single-staged or a two-staged procedure. Regardless, this type of major surgery entails considerable neurological risks. Therefore, thorough planning of the intervention and considerable surgical experience is needed. We present an elderly woman with gross restriction of forward gaze and intractable nuchal and radicular pain due to cervical spine deformity. Her cervical kyphosis was corrected using preoperative skeletal axial traction for four days and subsequent operative reduction with circumferential instrumentation and fusion. The post-operative course was complicated by a temporary anterior spinal artery syndrome despite normal intraoperative somatosensory evoked potentials (SSEP) and by a wound infection requiring removal of the implant. Nevertheless, segmental fusion in physiological alignment was successfully achieved and the patient fully recovered from the neurological deficit and infection. Quality of life was significantly improved.

[Anterior spinal artery syndrome due to cervical spondylosis presenting as cervical angina]

A 54-year-old woman developed acute progressive paraparesis after repeated precordial pain. Neurological examination revealed bilateral four-limb weakness predominant in the distal part of the upper limbs, upper limbs brisk tendon reflexes, superficial sensory impairment below the C8 level, and atonic bladder. T2-weighted cervical MRI disclosed hyperintense lesion with disc herniation in gray matter of spinal cord between C5 and C7. No vertebral artery abnormalities were detected. We hypothesized that she developed anterior spinal artery syndrome after cervical angina caused by cervical spondylosis. We conclude that physicians need to be aware of patients who experience chest pain without evidence of cardiac disease and that they take into consideration spinal cord infarction.

Blood distribution to the anterior spinal artery from each segment of intercostal and lumbar arteries

AIM

Prevention of paraplegia, a serious complication of surgery for thoracoabdominal aortic aneurysm, has been well documented. However no assured prophylaxis against this complication has yet been found. Spinal ischemia is believed to be the major cause of paraplegia. We conducted an experimental study to define the development of paraplegia with regard to the blood supply to the spinal cord.

METHODS

A porcine model was used to evaluate blood distribution to the anterior spinal artery. Colored silastic agent was selectively injected into the intercostal and lumbar arteries, and distribution to the anterior spinal artery was evaluated on 50 animals. The intercostal and lumbar arteries were ligated in the segments where the blood supply to the anterior spinal artery would be interrupted. Whether or not paraplegia developed was checked 2 days later.

RESULTS

Colored silastic agent arrived at the anterior spinal artery from all segments of the 8th intercostal to 4th lumbar arteries. Two of 9 pigs (22.2%) that underwent ligation of the segments from the 9th intercostal to 2(nd) lumbar artery suffered paraplegia. In 3 non-paraplegic pigs, colored silastic agent injected into the preserved arteries was found to have covered a wider range.

CONCLUSION

All the intercostal and lumbar arteries supplied blood to the anterior spinal artery. When large segments of intercostal and lumbar arteries were ligated, the blood flow from the preserved segments acquired increased dominance. The possibility exists that any intercostal and lumbar artery can supply blood to the spinal cord and become collateral circulation to the anterior spinal artery.

Computed tomography angiography assessment of Adamkiewicz artery with sublingual nitroglycerin administration

PURPOSE

Identification of the Adamkiewicz artery before aortic surgery is important for preventing postoperative complications due to spinal cord ischemia. The Adamkiewicz artery is difficult to identify due to its small diameter. Nitroglycerin has a vasodilatory effect and is used clinically to improve visualization of blood vessels on coronary computed tomography (CT) angiography. We investigated whether the vasodilatory effect of nitroglycerin could improve the ability to visualize the Adamkiewicz artery.

METHODS

We extracted 33 cases wherein contrast-enhanced CT images were taken before and after aortic aneurysm surgery. Nitroglycerin was administered for coronary artery evaluation on the preoperative CT. However, no nitroglycerin was administered before the postoperative CT. Aortic contrast-to-noise ratio, CT value, image noise, and diameter of the Adamkiewicz artery and anterior spinal artery were measured. The depiction of the Adamkiewicz artery was graded into four grades and evaluated. These measurements were performed by two independent reviewers.

RESULTS

In nitroglycerin-administered cases, the contrast-to-noise ratio and CT values were significantly higher (P < 0.001, P < 0.001, respectively); the Adamkiewicz artery and anterior spinal artery diameters were dilated (P = 0.005, P = 0.001, respectively). The Adamkiewicz artery score also improved significantly (P < 0.001). No significant difference was found in image noise.

CONCLUSION

Nitroglycerin contributed to improving the Adamkiewicz artery's visualization.

Anterior spinal artery syndrome after infrarenal abdominal aortic surgery

BACKGROUND

Neurological complications such as paraplegia or paraparesis due to spinal cord ischemia has been an unpredictable, devastating event after infrarenal abdominal aortic surgery. The aim of our study is to focus the importance of this entity and in this connection to review the vascular anatomy of the spinal cord, incidence and etiology of spinal cord ischemia, methods of prevention, and management of the patient.

METHODS

Eight patients were identified with spinal cord ischemia manifested by paraplegia or paraparesis after 1331 abdominal aortic operations. All the patients who had spinal cord ischemia were examined for risk factors.

RESULTS

Three anterior spinal artery syndrome neurological recovery occurred but 5 of them remained unchanged. Two patients died within 30 days of operation.

CONCLUSIONS

Complete paraplegia due to ischemic spinal cord injury was thought to be caused by interruption of critical collateral blood supply to the spinal cord. For this reason avoidance of prolonged aortic cross clamp time, hypotension, and its associated low flow to the spinal cord, paying attention to prevent atheromatous embolization of Adamkiewicz artery and pelvic circulation can prevent this complication. If the greater medullary artery is anomalously low from the anatomic localization the blood supply of the cord may be inadequate, so this complication cannot be avoided.

[A case of benign postpartum anterior spinal artery syndrome with thrombocytosis and high fibrolytic activity]

A 35-year-old woman was admitted to our hospital with acute onset paraparesis, sensory disturbance in her lower body, and urinary disturbance. She had given birth by normal vaginal delivery 6 days before the onset of these symptoms. On admission, paresis of her left leg was more severe than that of her right leg. Deep tendon reflexes of her lower limbs were hyperactive, and bilateral Babinski reflexes were observed. The patient's thermal and pain sensations below the lumbus were impaired. She lost bladder-filling sensation and bladder control. She showed an anterior spinal artery syndrome. Blood analysis revealed thrombocytosis and high fibrolytic activity. MRI of the brain and spinal cord did not show any lesions. Cerebrospinal fluid measurements showed that parameters were within the normal range and that the protein levels were not increased. We considered that a spinal cord infarction had occurred. After administration of antithrombotic agents and methylpredonisolone, her symptoms gradually improved. The coagulation disorders during the peripartum period were assumed to be a cause of anterior spinal artery syndrome in this case. It is very rare for perinatal women to have a spinal cord infarction. Only 3 cases of spinal cord infarction during the perinatal period have been reported thus far.

[Cervical medullar infarction in multileveled discopathy]

Spinal cord infarction is a rare but devastating pathology causing acute neurological deficits. The incidence has been estimated to 1% of all strokes. In that case report, our patient has presented anterior spinal artery infarction in C5-C6. The only risk factor founded was a multileveled discopathy wich is known to be an uncommon cause of anterior spinal artery syndrome.

Postoperative epidural analgesia and possible transient anterior spinal artery syndrome

BACKGROUND AND OBJECTIVE

We present an unusual complication of epidural analgesia used to facilitate postoperative pain relief while allowing mobilization of the patient.

CASE REPORT

A 65-year-old woman with a history of chronic obstructive pulmonary disease, atherosclerotic cardiovascular disease, chronic renal failure, and degenerative vertebral anatomy underwent resection of the left ureter due to obstructing tumor. The day following surgery, mobilization to an armchair was started, followed by a decrease in blood pressure. Soon after, flaccid paralysis with sparing of sensory functions, consistent with anterior spinal artery syndrome (ASAS), was diagnosed.

CONCLUSIONS

This complication should be taken into account, especially in patients at risk, when considering epidural analgesia techniques in the postoperative period. Reg Anesth Pain Med 2001;26:274-277.

Anterior spinal artery syndrome after thoracic surgery

Spinal cord infarction is a rare complication following thoracic surgery. We present a case who developed paraplegia on the first postoperative day of thoracotomy. A 76-year-old man with a history of atherosclerotic cardiovascular disease was operated for bronchial carcinoma. An epidural infusion of ropivacaine and sufentanil was used for postoperative pain. Eight hours after the surgery, he had an episode of hypotension and respiratory depression. One hour later, he described paraplegia and Ischemia of the spinal cord was found on MRI. There was no recovery during the follow-up.

Mechanisms and prevention of anterior spinal artery syndrome following abdominal aortic surgery

Paraplegia or paraparesis occurring as a complication of thoracic or thoracoabdominal aortic aneurysm repair is a well known phenomenon, but the vast majority of elective abdominal aortic aneurysm repairs are performed without serious neurological complications. Nevertheless, there have been many reported cases of spinal cord ischaemia following the elective repair of abdominal aortic aneurysms (AAA); giving rise to paraplegia, sphincter incontinence and, often, dissociated sensory loss. According to the classification made by Gloviczki et al. (1991), this presentation is classified as type II spinal cord ischaemia, more commonly referred to as anterior spinal artery syndrome (ASAS). It is the most common neurological complication occurring following abdominal aortic surgery with an incidence of 0.1-0.2%. Several aetiological factors, including intra-operative hypotension, embolisation and prolonged aortic crossclamping, have been suggested to cause anterior spinal artery syndrome, but the principal cause has almost always been identified as an alteration in the blood supply to the spinal cord. A review of the literature on the anatomy of the vascular supply of the spinal cord highlights the significance of the anterior spinal artery as well as placing additional emphasis on the great radicular artery of Adamkiewicz (arteria radicularis magna) and the pelvic collateral circulation. Although there have been reported cases of spontaneous recovery, complete recovery is uncommon and awareness and prevention remains the mainstay of treatment. However, being so tragically unpredictable and random, spinal cord ischaemia after abdominal aortic operations appears to be an unpreventable event.

Anterior Spinal Artery Syndrome Due to Fibrocartilaginous Embolism-Case Report and Treatment Options

Acute occlusion of the anterior spinal artery and subsequent spinal ischemic infarction leads to anterior spinal artery syndrome characterized by back pain and bilateral flaccid paresis with loss of protopathic sensibility. As a rare cause fibrocartilaginous embolism has been described and is associated with sports or unusual strain.Following gymnastic exercise the day before symptom-onset, a 11 years old girl presented with neck pain, paresis of arms and legs, and impaired deep tendon reflexes. She was unable to lift her arms, grasp, stand, walk and had urinary incontinence. Magnetic resonance imaging revealed a longitudinal T2 hyperintense signal in the anterior spinal cord from C3 to C6 with accompanying bilateral diffusion restriction involving gray matter bilaterally at the level of C4 and C5 and unilaterally at the level of C3/4. The adjacent annulus fibrosus of the intervertebral disc showed a fissure without disc protrusion. Treatment with prednisolone and enoxaparin was started within 12 hours of symptom-onset and continued over 6 days and 8 weeks, respectively. After 2 months, her motor function gradually improved, spinal imaging showed persistent T2 signal hyperintense defects at the level of C4/5. After 5 months, there was only slight impairment affecting elevation and abduction of the right arm.Following physical exercise, the patient suffered from acute anterior spinal cord ischemia with imaging findings in line with a presumed fibrocartilaginous embolism. Unlike most cases, our patient showed almost complete recovery following treatment with prednisolone and enoxaparin. We speculate that the positive outcome is related to rapid treatment initiation.

[Paraplegia following a transurethral prostate resection: the anterior spinal artery syndrome]

A 73-year-old man with an extensive cardiovascular risk profile and history underwent a transurethral resection of the prostate under spinal anaesthesia. The use of acetylsalicylic acid was stopped 10 days before the operation. No anaesthesiological or surgical complications occurred during the operation, but 6 hours after the operation the patient developed severe pain in both legs. Besides the hyperalgesia, there was a paresis and a reduced sensitivity of the legs. The patient had developed anterior spinal artery syndrome due to ischaemia of the lower thoracic myelum. Despite intensive rehabilitation this ultimately resulted in a residual disability and the patient became wheelchair bound. There seems to be a correlation between the patient's comorbidity, the stopping of the thrombocyte aggregation inhibitor and the occurrence of this particularly rare complication.

[An adult case of primary antiphospholipid syndrome presenting recurrent anterior spinal artery syndrome]

A 50-year-old man suffered from sudden onset of paraplegia, sensory impairment of the lower extremities and difficulty urinating. These symptoms spontaneously resolved, and he was able to walk again within 10 days. After 2 months' observation, he experienced a relapse with identical symptoms. Neurological examination revealed paraplegia, hypalgesia and hypesthesia in the lower extremities and difficulty urinating. Position and vibration senses were preserved in the extremities. Knee jerk was mildly hyperreflexic on the left, but pathological reflexes were not present. He had such risk factors for arteriosclerosis as diabetes mellitus, hypercholesterolemia and smoking. Although antinuclear antibodies were negative, he repeatedly showed high anticardiolipin antibody titers. MRI showed a T2-hyperintense lesion of the anterior portion of the spinal cord at Th9-10 levels. Neither arteriovenous malformation nor fistula was found on MR angiography. Abdominal CT revealed no abnormality in the descending aorta. Cervical ultrasonogram showed arterioslerotic lesions on the right common carotid artery. This is the first report of recurrent spinal cord infarction in an adult patient associated with primary antiphospholipid syndrome. Recurrence of the spinal cord infarction in this case may have been facilitated by the presence of risk factors for arteriosclerosis.