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Cardiac risk factors were evaluated in 48 persons (39 males, 9 females) with quadriplegia or paraplegia, resident in a specialized spinal injury hospital and seen 0.3 +/- 0.7 years after their spinal injury. The majority of the patients reported being extremely active physically prior to injury. Limited activity in the hospital involved the use of ergometers, pulleys, and weights; however, the majority of subjects expressed a wish for more exercise. Serum lipid profiles showed a relatively normal total cholesterol (mean 4.58 +/- 0.77 mmol/L), a very low high-density lipoprotein-cholesterol (0.91 +/- 0.27 mmol/L), a relatively normal low-density lipoprotein-cholesterol (2.86 +/- 0.68 mmol/L) and high triglycerides (1.89 +/- 0.88 mmol/L). Resting blood pressures were normal. The percentage of smokers (25%) was similar to the percentage of smokers in the general population, but many had quit smoking subsequent to hospitalization. Family histories and diet gave no evidence of increased cardiac risk. We conclude that individuals who sustain a spinal injury do not have a large inherent risk of cardiac events. In persons with paraplegia, cardiac problems develop mainly from the cumulative impact of reduced physical activity and a resulting adverse lipid profile. There may also be a reactive deterioration in other aspects of personal lifestyle, such as cigarette smoking after leaving the hospital. In high-level lesions, factors such as hypertension and a poor stroke volume with compensatory tachycardia may increase cardiac work rate during attempts at ambulation, further predisposing an individual to myocardial ischemia and cardiac arrest.
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PMID:Cardiac risk factors immediately following spinal injury. 823 48

Between 1981 and 1987, 88 consecutive patients were operated on for a thoracoabdominal aortic aneurysm by simple crossclamping and a graft inclusion technique (without shunts or heparin). This article presents an analysis of the operative outcome and long-term follow-up. Patient- and operation-related variables are age (mean 64.3 years, range 28 to 82 years), sex (82% men), rupture (20.5%), diabetes (2.3%), renal insufficiency (34.1%), chronic obstructive pulmonary disease (27.3%), previous aortic operation (31.8%), arterial hypertension (66%), postdissection (18.2%) versus degenerative (80.7%) origin, preoperative shock (11.4%), ischemic cerebrovascular (12.5%) or ischemic heart (17%) disease, peripheral vascular disease (14.8%), renal (mean 48 minutes, range 0 to 83 minutes) and lower spinal cord (mean 21 minutes, range 0 to 68 minutes) ischemic time, number of reattached intercostals, blood loss, and extent of the aneurysm (Crawford classification: type I, 16 patients [18.2%]; type II, 21 patients [23.8%]; type III, 29 patients [33%]; and type IV, 22 patients [25%]. Intraoperative mortality is 1.1% (n = 1). Thirty-day mortality is 5.9% (n = 5). Hospital mortality is 11.4% (n = 10): 7% for elective cases and 28% for ruptured aneurysms (p = 0.014). The survival at 2 years is 78% +/- (4.4%) and at 5 years 54% +/- (5.3%). Postoperative spinal cord injury occurred in 12 patients (13.8%) (5 had paraplegia and 7 had paraparesis) and postoperative renal dysfunction necessitating dialysis in 12 patients (14.1%). Risk stratification for hospital death, late death, renal failure, and spinal cord dysfunction was performed by means of multivariate logistic regression and Cox proportional hazard regression as appropriate. The best fitting model to predict hospital death includes preoperative shock (p = 0.02), female sex (p = 0.06), preoperative elevated serum creatinine level (p = 0.06), and preoperative myocardial infarction (p = 0.08). Variables predictive for late death are postoperative dialysis (p = 0.002), age (p = 0.008), and rupture (p = 0.04). The risk factors of postoperative dialysis are age (p = 0.003) and preoperative serum creatinine level (p = 0.04). The risk of postoperative spinal cord dysfunction increases with longer lower spinal cord ischemic time (p = 0.02) and with the presence of preoperative shock (p = 0.06).
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PMID:Surgical treatment of thoracoabdominal aortic aneurysms by simple crossclamping. Risk factors and late results. 828 76

A 32-year-old man sustained a severe head injury in a road traffic accident. On admission, he was in deep coma (6 on the Glasgow coma scale). The aortic knuckle was difficult to identify on a plain chest film. Twenty hours after admission, the aortic knuckle had completely disappeared and the mediastinal shadow had become enlarged. The diagnosis of a ruptured aortic isthmus was confirmed by angiography. Surgical repair of this lesion may be carried out either with simple aortic cross-clamping, or by using cardiopulmonary bypass (CPB). Either technique may worsen other injuries, especially head injury, by initiating severe arterial hypertension or coagulation disturbances. In this patient, the technique chosen was aortic cross-clamping with permanent monitoring of the intracranial and cerebral perfusion pressures. Anaesthesia was obtained with 5 mg.kg-1 of thiopentone, 30 mg.kg-1 x h-1 of sodium gamma hydroxybutyrate and 8 micrograms.kg-1 x h-1 of fentanyl. Surgery lasted for 90 min, with 33 min of aortic clamping. The increase in arterial blood pressure was controlled with 0.25 mg.kg-1 x h-1 of thiopentone and nicardipine which was stopped 8 min before unclamping. The postoperative course was uneventful. Sedation was stopped after 8 days, and the patient regained consciousness two days later. These remained a paraplegia with no sensory deficit, which had totally receded 15 months later. Carrying out this emergency surgery without CPB means that the intracranial pressure must imperatively be monitored during surgery. Any intracranial hypertension should delay the surgery.
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PMID:[Traumatic rupture of the aortic isthmus in a patient with severe head injury]. 833 63

Acute aortic dissection is the most common fatal condition that involves the aorta; nevertheless, despite major advances in noninvasive diagnosis, the correct antemortem diagnosis is made in less than half the cases. To promote continued improvement in the prompt recognition of aortic dissection, we present a review of the Mayo Clinic experience with 235 patients who had 236 substantiated aortic dissections. At the time of initial assessment, 158 patients (67%) had acute and 78 patients (33%) had chronic aortic dissection. Hypertension was the most common predisposing factor (78% of patients overall). The acute onset of severe chest pain was the most common initial complaint (74%), but 33 patients (15%) had painless aortic dissection and abnormal chest roentgenographic findings. Less common manifestations included congestive heart failure, syncope, cerebrovascular accident, shock, paraplegia, and lower extremity ischemia. The initial clinical impression was aortic dissection in 62% of patients overall. In 17 patients (28%), the correct diagnosis was not made before postmortem examination. Although the clinical features of aortic dissection have gained wider appreciation, the diagnosis still remains unsuspected in a substantial number of patients. In a patient who has a catastrophic illness and unexplained symptoms that could be of vascular origin, especially in the presence of chest pain, aortic dissection should always be included in the differential diagnosis.
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PMID:Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990). 1188 38

In a 20-year-old female patient with a brain stem glioma in the medulla oblongata in association with paraplegia and respiratory paralysis, bradyarrhythmias such as sinus bradycardia and sinus arrest repeated sporadically and transiently, but soon subsided as radiotherapy was being delivered to the glioma in the medulla oblongata. The bradyarrhythmias were differentiated from sick sinus syndrome in their sporadic and transient character. The patient responded normally to atropine, isoproterenol, and phenylephrine. Parasympathetic nerve reflexes induced by Aschner's, Czermak's, and Valsalva's maneuvers and sympathetic nerve reflex induced by change of body position were within normal limits. Although EKG abnormalities associated with diseases of the central nervous system are frequently due to intracranial hypertension and/or irritation of the hypothalamus, the bradyarrhythmias in this patient were possibly due to vagus stimulation caused by the glioma in the medulla.
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PMID:[A case of sporadic and transient bradyarrhythmias in a patient with a glioma in the medulla oblongata]. 835 39

The reduced early mortality and the increased life span of persons with spinal cord injury (SCI) and other chronically disabling conditions which result in loss of use of the legs places them at increased risk of coronary heart disease, diabetes, and hypertension. Exercise testing in this population is becoming more common, but there is a need for assessment of protocols in order to determine the best method to elicit a maximal response in a reasonable time without endangering the patient. Three wheelchair treadmill protocols were compared in seven men with paraplegia aged 21-44 years (five SCI, two post-polio). Subjects repeated each protocol to estimate reliability. Protocol G consisted of increasing treadmill grade at a constant speed (4.8 km.h-1); in protocol S, the speed was increased at a constant grade (0%), and in protocol C, speed and grade were increased. Two-minute stages were used in all protocols. Peak oxygen uptake [VO2max; mean (SD): 23.6 (5.8) ml.kg-1 x min-1; 1.66 (0.37) l.min-1], VCO2 production [1.98 (0.46) l.min-1], ventilation volume [83.0 (25.6) l.min-1], respiratory exchange ratio [1.2 (0.12)], and heart rate [173 (18)] were determined. Over all trials none of the variables was significantly different among the three protocols, but all were highest in C and lowest in S. Reliability coefficients for absolute and relative VO2max ranged from 0.76 and 0.81 in G to 0.95 and 0.98 in C (all P < 0.05). These data suggest that an incremental treadmill test similar to the C protocol may be the optimal method to use when evaluating the exercise capacity of wheelchair users.
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PMID:Comparison of treadmill exercise testing protocols for wheelchair users. 849

The purpose of this study was to assess the usefulness of left heart bypass in thoracoabdominal aortic aneurysm surgery. Data from 50 patients who underwent thoracoabdominal aortic aneurysm repair between July 1987 and October 1993 were retrospectively reviewed. In all of them a left heart bypass (left atrium to left femoral artery) with a centrifugal pump (without systemic heparinization) was used. Patient-, disease-, and operation-related variables were analyzed using univariate methods. There were no intraoperative deaths. The in-hospital mortality rate was 8% (n = 4). Survival rates were 77% (+/- 6.5) at 2 years and 62% (+/- 8.7) at 5 years. Renal failure requiring dialysis occurred in five (10%) patients and paraplegia in five (10%). Sixteen (32%) patients had respiratory insufficiency requiring prolonged (> 8 days) ventilation. After univariate analysis, the risk factors for developing a need for postoperative dialysis were found to be the preoperative creatinine level (p = 0.002) and the presence of preoperative arterial hypertension (p = 0.018). A history of peripheral vascular occlusive disease (p = 0.008) was an important risk factor for predicting late death. No factors retained significance in the univariate analysis of hospital deaths and postoperative paraplegia. Renal and spinal ischemic times were substantially reduced in comparison to the theoretic times calculated if cross-clamping had been used. Bypass-related complications were completely absent. The use of a left heart bypass during thoracoabdominal aortic aneurysm surgery may not reduce the global complication rate; the results were similar to those achieved using simple cross-clamping. However, this technique appears to be the method of choice for protecting organ systems at risk during difficult repairs.
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PMID:Use of left heart bypass in the surgical repair of thoracoabdominal aortic aneurysms. 852 32

In previous articles on the Stockholm Spinal Cord Injury Study (SSCIS), we have reported the frequent occurrence of medical problems in a near-total regional SCI population comprising 353 subject. This present study further investigates health-related issues in this SCI population, by a level-of-living survey that has been used annually on 8000-14,000 Swedes since 1974. The health-focused version of this survey was used for data collection in those 326 subjects in the SSCIS who were residents of the Greater Stockholm area. Subjects of the SSCIS living on the island of Gotland were excluded because they represented a sociodemographically different (rural) population. The normative material consisted of 1978 interviews of residents of the Greater Stockholm area, provided by the Swedish Bureau of Statistics. Results show a higher utilisation of health care resources among SCI subjects, shown by higher rates of long-term sick leave and sick pension, and more treatment as inpatients, emergency room attendees, and outpatients. Pain, bladder problems, and psychological symptoms are more commonly reported by SCI subjects. Medications such as antibiotics, analgesics, sedatives, hypnotics and laxatives are used more frequently in the SCI group. In contrast, no statistically significant differences were found as regards reported prevalence of diseases other than SCI, including diabetes, hypertension and cardiac disease. The results thus verify the impression from our previous studies of a clearly increased morbidity among these SCI subjects. The increased morbidity seems to be accounted for by the SCI itself, or conditions directly caused by it.
Paraplegia 1995 Dec
PMID:The Stockholm Spinal Cord Injury Study. 3. Health-related issues of the Swedish annual level-of-living survey in SCI subjects and controls. 892 13

We report a 57-year-old woman with optic-spinal form of active multiple sclerosis, who developed a large lobar type hemorrhage of the brain. She initially suffered from left visual loss, and three month later, she was hospitalized with paraplegia and total sensory loss up to the fourth thoracic level accompanied by sphincteric disturbance. Diagnosis of clinically probable multiple sclerosis was based on the relapsing-remitting clinical course and laboratory findings. Five months after admission, she developed sudden consciousness loss. Brain CT scan showed a massive hemorrhage in the right frontal to parietal lobe. The patient had no risk factors for cerebral hemorrhage including hypertension. Histopathological study of brain tissues obtained at surgical evacuation of hematoma did not reveal any malignancy, and congo-red staining of this specimen was negative. We analyzed coagulation, fibrinolytic, and endothelial parameters during the follow-up period. von Willebrand factor (vWF) as a marker for endothelial damages was elevated persistently. Moreover, thrombin-antithrombin III complex (TAT) as a marker for activation of coagulation was also elevated constantly throughout the clinical course. The findings suggest that fragility of the vascular walls and permeability changes associated with immunological mechanisms might have resulted in the cerebral hemorrhage. Although there are few reports of cerebral hemorrhage in patients with multiple sclerosis, it has been reported that vascular wall damage is an important aspect of the pathology of multiple sclerosis and acute cerebral vascular damage may sometimes occur in multiple sclerosis. We propose that coagulation studies including the endothelial marker such as vWF would provide a useful information regarding the risk of cerebrovascular complication in multiple sclerosis.
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PMID:[A case of optic-spinal form of multiple sclerosis with lobar type large cerebral hemorrhage]. 939 61

Postoperative paraplegia remains the most devastating complication of surgery of the descending and thoraco-abdominal aorta. Control of the proximal hypertension that follows cross-clamping of the thoracic aorta to repain aneurysms of the descending and thoraco-abdominal aorta is necessary to prevent left ventricular failure, myocardial infarction, and hemorrhagic cerebral events. Both pharmacological and mechanical modalities used to control central hypertension during aortic occlusion affect cerebrospinal fluid dynamics and spinal cord perfusion pressure. Sodium nitroprusside (doses >5 microg/kg/min), the most widely used pharmacological agent, decreases spinal cord perfusion pressure because it increases cerebrospinal fluid pressure and decreases blood pressure distal to the aortic cross-clamp. This effect cannot be prevented by drainage of cerebrospinal fluid. Nitroglycerin also decreases spinal cord perfusion pressure, but its effects on cerebrospinal fluid dynamics can be countered by drainage of cerebrospinal fluid. Active distal perfusion with left atrial-femoral artery bypass can provide adequate perfusion of the circulation distal to the aortic cross-clamp while simultaneously reducing cerebrospinal fluid pressure. This approach can maintain mesenteric and spinal cord blood flow, therefore preventing the multiple organ dysfunction syndrome caused by release of cytokines from the splanchnic district and decreasing the incidence of postoperative paraplegia from spinal cord ischemia. In cases of limited retroperfusion, partial exsanguination and cerebrospinal fluid drainage can be used in conjunction with left atrial-femoral artery bypass to prevent rises in cerebrospinal fluid pressure and maintain spinal cord blood flow above the threshold necessary to prevent neurological injury. The use of oxygenated perfluorocarbons in the subarachnoid space to provide passive oxygenation of the spinal cord during aortic occlusion remains experimental and requires further investigation.
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PMID:Control of proximal hypertension during aortic cross-clamping: its effect on cerebrospinal fluid dynamics and spinal cord perfusion pressure. 946 79


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