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Query: UMLS:C0022116 (ischemia)
 91,303 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

There remains no consensus on the operative management of Thoracoabdominal aortic aneurysm (TAA). Our approach emphasizes operative expediency and simplicity (without circulatory assist techniques), avoiding anticoagulation and systemic hypothermia. The technique involves a fundamental clamp/sew method with specific adjuncts directed against the principle complications: epidural cooling (introduced in 1993) for spinal cord protection, regional renal hypothermia, and in-line mesenteric shunting to minimize visceral ischemia. In a cohort of over 200 TAA patients (50% Types I & II) treated during the past decade perioperative mortality has been 8% and paraparesis/paraplegia occured in 7%. These figures are halved for patients treated in elective circumstances.
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PMID:Thoracoabdominal aortic aneurysm repair: how I do it. 1051 67

Primary bacterial aortitis represents a rare disease with a high lethality. From June 1997 to April 1999 5 patients with an abdominal aortic infection were treated by resection of the infected aorta and in-situ reconstruction or by extra-anatomic bypass. There was no treatment in one case because of the infaust prognosis. 3 patients survived, one with a paraparesis as a result of spinal ischemia. On the basis of our patients the pathogenesis, clinical symptoms with diagnosis and the therapeutic options are discussed.
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PMID:[Primary bacterial aortitis]. 1076 48

Paraplegia remains to be one of the most dangerous complications following thoracoabdominal aortic surgery with an incidence of 0.5 to 40%. Therefore, intraoperative monitoring of spinal cord function is very important when choosing the appropriate surgical technique. Early detection of spinal cord injury continues to be a crucial problem, moreover, the currently applied electrophysiological methods appear to be inaccurate. The aim of the study was to detect prospective spinal cord injury intraoperatively by monitoring the biochemical parameters of the cerebrospinal fluid (CSF). The authors studied the reversible aerobic/anaerobic metabolic changes by monitoring CSF lactate levels, moreover S-100 protein and neuron-specific enolase (NSE) concentrations--specific for neuroglia and neuronal injury, respectively. One of the important methods to prevent paraplegia is the intraoperative CSF drainage, which may improve spinal cord perfusion. Between 1996-1998 51 patients underwent reconstructive thoracic or thoracoabdominal aortic aneurysm operation. The continuously drained CSF was collected in 10 ml fractions during the preparation, whereas during aortic cross-clamping and de-clamping 10 minute fractions were used. All CSF samples were immediately analysed intraoperatively for pH, pCO2, HCO3, potassium and lactate levels, S-100 protein and NSE were analysed by immunoluminescence. CSF lactate levels increased slightly during aortic clamping and a moderate, but non-significant increase was found in the hyperemic phase (reperfusion) in patients without spinal cord ischemia. Spinal cord injury was detected in 7 cases. These patients exhibited a significant CSF-lactate increase (control vs aortic cross-clamping: 1.9 vs 5.3 mmol/l), moreover CSF-lactate remained elevated throughout the whole operation. Paraplegia did not occur, Tarlov 2 paraparesis developed in four cases and three patients displayed cerebral damage. Intraoperative CSF--especially CSF-lactate--monitoring may help the operating team to detect early anaerobic changes of the metabolism the spinal cord.
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PMID:[New method for the intraoperative biochemical monitoring of cerebrospinal fluid in surgery of thoracoabdominal aortic aneurysms]. 1093 38

We reviewed the clinical and neuroradiological features in 16 patients with serious neurological complications of lumbar epidural anaesthesia. We observed acute, transient or permanent and delayed complications. Four patients had symptoms immediately after the procedure. One patient developed a subacute flaccid paraparesis. Two other patients had infectious spondylodiscitis at lumbar puncture level. Eight patients had a delayed progressive spastic paraparesis and were found to have subarachnoid cysts and irregularities of the surface of the spinal cord consistent with arachnoiditis; six of them had an extensive, complex syrinx within the cord. One patient had a severe lumbar polyradiculopathy, and MRI showed adhesive arachnoiditis involving the cauda equina. Although epidural anaesthesia is generally considered safe, rare but severe complications, such as radiculopathy, infectious disease, myelopathy from ischemia and arachnoiditis with a syrinx may occur. The patients with arachnoiditis had a relentless progression of the disease and a poor outcome: five are confined to a wheelchair, one is bedridden. Complications of epidural anaesthesia are easily recognised when they develop immediately; their relationship to the anaesthesia may be ignored or underestimated when they appear after a delay. Awareness of the possibility of delayed complications is important.
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PMID:Imaging and outcome in severe complications of lumbar epidural anaesthesia: report of 16 cases. 1099 61

Paraplegia caused by spinal cord ischemia remains a devastating complication after surgical repair of thoracoabdominal aortic aneurysms. Cerebrospinal fluid (CSF) drainage has been advocated as a protective adjunct to reduce the incidence of postoperative neurologic deficits. Studies in animals have shown that CSF drainage during thoracic aortic clamping reduces CSF pressure, improves spinal cord blood flow, and prevents paraplegia. Previous retrospective and randomized clinical studies, however, have been inconclusive because of confounding factors and other limitations. A recent prospective randomized trial focusing solely on CSF drainage during repair of extent I and II thoracoabdominal aortic aneurysms indicated an 80% reduction in the relative risk of paraplegia and paraparesis in patients who received this adjunct. Consequently, CSF drainage has emerged as an important addition to the multimodality strategy for preventing postoperative spinal cord deficits.
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PMID:Cerebrospinal fluid drainage in thoracoabdominal aortic surgery. 1115 59

As contemporary adjuncts have substantially reduced the overall incidence of paraplegia and paraparesis after the surgical repair of thoracoabdominal aortic aneurysm, delayed-onset neurologic deficit has emerged as a significant clinical entity. It is generally agreed that neurologic deficits are attributable to the duration of spinal cord ischemia sustained during aortic cross-clamping. Factors known to increase the risk of spinal cord injury include the aneurysm extent, aortic cross-clamp time, aneurysm rupture, and associated acute aortic dissection. Clinically and experimentally, studies have shown different adjuncts to improve spinal cord protection, providing further insights into the pathophysiology of spinal cord ischemia. However, the pathophysiology of delayed-onset spinal cord deficit after thoracoabdominal aortic aneurysm repair remains largely controversial. This review discusses the significance and management of delayed-onset neurologic deficit.
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PMID:Delayed onset of neurologic deficit: significance and management. 1115 63

Sixty-five consecutive patients undergoing nonemergent repair of an abdominal aortic aneurysm (AAA) originating above the visceral and/or renal arteries were studied to determine operative results and identify factors influencing outcome of proximal AAA repair. Factors associated with postoperative morbidity were analyzed using multivariate analysis. There were no postoperative deaths, paraplegia/paraparesis, or symptomatic visceral ischemia. Proximal AAA repair can be accomplished with acceptable mortality. If renal artery bypass or reimplantation is anticipated, cold renal perfusion may protect against renal dysfunction. Postoperative pulmonary dysfunction can be reduced by avoiding radial division of the diaphragm.
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PMID:Factors affecting outcome in proximal abdominal aortic aneurysm repair. 1166 33

Diffusion-weighted MR (DWI) is becoming an established method for the investigation of cerebral ischemia. Its value in spinal ischemia has to be demonstrated. We report on a patient presenting with postoperative paraparesis who underwent emergency MRI of the spine with echo-planar diffusion-weighted imaging which showed an area of hyperintensity corresponding to a decrease of diffusion as measured by the apparent diffusion coefficient. On follow-up imaging spinal stroke was confirmed. In conclusion, spinal echo-planar MR imaging can demonstrate ischemic changes despite strong echo-planar artifacts. It could become an important adjunct to the management of patients with suspected spinal ischemia.
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PMID:Anterior spinal artery stroke demonstrated by echo-planar DWI. 1173 67

Morbidity of infrainguinal bypass surgery is mostly related to cardiac complication, graft thrombosis, and wound infections. Neurologic complications in these patients are unusual and generally related to traumatic peripheral nerve injury or ischemia. Anterior spinal cord ischemia, manifest clinically as flaccid paraplegia or lower extremity paraparesis, is a complication usually associated with aortic surgery. Reported here is a case of an 81-year-old male who developed spinal cord ischemia after infrainguinal bypass under epidural anesthesia.
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PMID:Anterior spinal cord ischemia after infrainguinal bypass surgery. 1176 58

Thoracoabdominal aneurysm surgery is associated with a high incidence of morbidity and mortality. Spinal cord ischemia and the risks of paraparesis or paraplegia remain devastating complications. The mechanisms of spinal cord injury involve both acute ischemic injury and delayed reperfusion injury. Blood flow to the spinal cord frequently arises in the segment of the aorta requiring aortic cross clamping. As such, there is an obligate period of blood flow disruption. Multiple strategies have evolved to reduce the ischemic interval and to provide adjunct interventions to reduce the impact of the ischemia. Despite a multidisciplinary approach, a spinal cord ischemia is present in approximately 4 to 16% of patients, depending on the type of aneurysm and other comorbid diseases. Cerebral spinal fluid drainage, distal perfusion techniques, intercostal artery anastomosis, hypothermia techniques, and mechanisms of ischemic preconditioning are interventions employed to reduce the risk of paraplegia after thoracal-abdominal aortic surgery. Surgeons, anesthesiologists, and perfusionist are intimately involved in the decision making as to which interventions will be employed in a given case. Although these adjuncts have been evaluated in multiple animal and human protocols, the efficacy of each intervention when looked at in isolation remains difficult to determine fully. This is attributable, in part, to the complex mechanisms of the patient injury, the inherint risks of the surgical procedure, and the confounding effects of comorbid disease states. Nonetheless, clinicians must have comprehensive understanding of these various interventions and their application. This review serves as an overview of these various interventions with special emphasis on outcome data.
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PMID:Thoracoabdominal aneurysm surgery and the risk of paraplegia: contemporary practice and future directions. 1191 23


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