Thrombosed aorta resulting in spinal cord ischemia and paraplegia in ischemic cardiomyopathy

Paraplegia due to Acute Aortic Coarctation and Occlusion

Coarctation and occlusion of the aorta is a rare condition that typically presents with hypertension or cardiac failure. However, neuropathy or myelopathy may be the presenting features of the condition when an intraspinal subarachnoid hemorrhage has compressed the spinal cord causing ischemia. We report two cases of middle-aged males who developed acute non-traumatic paraplegia. Undiagnosed congenital abnormalities, such as aortic coarctation and occlusion, should be considered for patients presenting with nontraumatic paraplegia in the absence of other identifiable causes. Our cases suggest that spinal cord ischemia resulting from acute spinal subarachnoid hemorrhage and can cause paraplegia, and that clinicians must carefully examine patients presenting with nontraumatic paraplegia because misdiagnosis can delay initiation of the appropriate treatment.

Acute infrarenal aortic thrombosis presenting with flaccid paraplegia

STUDY DESIGN

This study is a case report.

OBJECTIVE

To report a case of a patient with paraplegia and low back pain, who was diagnosed with acute infrarenal aortic thrombosis.

SUMMARY OF BACKGROUND DATA

There have been few reports in the literature regarding acute aortic thrombosis presenting with paraplegia.

METHODS

A 56-year-old man was referred to our emergency department with flaccid paraplegia and low back pain. Clinical examination and imaging revealed acute infrarenal aortic thrombosis, with lower limb ischemia. The patient underwent transcutaneous embolectomy.

RESULTS

Despite successful revascularization, the patient finally died because of development of revascularization syndrome.

CONCLUSION

Acute aortic occlusion is a catastrophic event and may present with paraplegia, because of acute spinal cord ischemia. This can mislead the clinician to a wrong diagnosis and delay initiation of definite treatment.

Ischaemic spinal cord injury following a coronary angiogram: a case report

A 50 year old man was undergoing a coronary angiogram in preparation for possible cardiac bypass surgery at Queen Alia Heart Institute (QAHI) in King Hussein Medical Centre (KHMC) in Amman, Jordan. At the end of the procedure, he suddenly developed low back pain and weakness of both lower limbs. Neurological examination revealed incomplete paraplegia below L1 with urinary retention. Urgent MRI scan suggested ischaemia of the lower part of the spinal cord. Literature search revealed that no such complication of this procedure, which is a common investigation in cardiac centres, has, to date, been reported. The possible causes of this patient's paraplegia are discussed.

Acute aortic occlusion--factors that influence outcome

PURPOSE

The purpose of this study was to report our experience in the management of acute aortic occlusion and to analyze factors that influenced the outcome.

METHODS

This was a retrospective analysis of 48 patients with acute aortic occlusion treated over a 19-year period. Presentation included limb ischemia in 34, acute abdomen in four, spinal cord compression-like symptoms in eight, and sudden onset of hypertension in two patients. Thrombosis was the cause of acute aortic occlusion in 44, and embolus in four patients. Acute thrombosis was associated with underlying atherosclerotic occlusive disease in 36 patients. In these, thrombosis was due to low-flow state caused by cardiac dysfunction or severe volume depletion. Thrombosed aneurysms caused aortic occlusion in two patients. Hypercoagulable state caused thrombosis of relatively normal aorta in six patients. Angiography in 39 patients revealed occlusion to be juxtarenal or infrarenal in 37 and suprarenal in two. Left ventricular function (LVF) was assessed in 42 patients. Circulation was restored in 45 (aortofemoral bypass in 22, axillofemoral bypass in 12, and thromboembolectomy in 11). This was not feasible in three patients. Additional surgical procedures were required in 29 patients (64%).

RESULTS

The overall mortality rate was 52% (25 of 48). Of the 20 patients with severely compromised LVF, 17 died (85%). In contrast, only five (23%) deaths occurred among 22 with good LVF. Among 29 patients who required additional operations, 18 died (62%). All four patients with embolic occlusion survived. Patients with normal LVF but hypercoagulable state had dismal outcome--only one of the six survived.

CONCLUSIONS

Acute aortic occlusion is infrequent. Presentation may be varied, thus delaying diagnosis. Poor LVF, thrombosis of arteries below the inguinal ligament or of visceral arteries, and "hypercoagulable state" portend ominous prognosis.

Acute thrombosis of the non-aneurysmal abdominal aorta

Fourteen patients admitted over a 9 year period with acute thrombotic occlusion of the non-aneurysmal abdominal aorta have been reviewed. Twelve patients underwent aortic bifurcation graft reconstruction, one thromboendarterectomy alone, and one a re-entry operation for dissection. Two patients (14%) died in the perioperative period. The mean postoperative survival of the remaining patients is to date 55 (range 4-93) months with a mean follow-up period of 69 (range 18-100) months. The results indicate these patients should be treated aggressively by early reconstructive surgery in the expectation that the majority will survive their operation and gain a useful extension to their lives.

Echocardiographic evaluation of patients with clinically suspected arterial emboli

153 patients (mean age 42 years, range 16-60) who had arterial embolic events were examined prospectively by transthoracic and transoesophageal echocardiography. Patients older than 60 years and those with evidence of extracranial carotid artery occlusive disease were excluded. 84 patients had a cerebral ischaemic event, 50 patients had embolic events in an abdominal organ or limb, and 19 patients had acute retinal ischaemia. The transthoracic echocardiographic examination was normal in 92 patients (60%), whereas only 65 patients (42%) had normal findings after both transthoracic and transoesophageal examination (p less than 0.005). Intracardiac masses, including valvular vegetations, were found in 39 patients (25%), including 27% of patients with cerebral embolism and 32% of these with peripheral embolism, but in none of the patients with retinal ischaemia (p less than 0.001). 47 patients (31%) had valvular disease, 10 (7%) had wall motion abnormalities, 23 (15%) had abnormalities of the interatrial septum, and 9 patients (6%) had diseases of the thoracic aorta. Cardiovascular abnormalities were frequently found by echocardiography in patients with arterial emboli. The transesophageal technique significantly increased the chance of detecting such abnormalities, especially intracardiac masses.

[Spinal cord infarction: clinical, electrophysiologic and laboratory diagnosis]

In the international, but more so in the latin-american, medical literature infarction of the spinal cord has been rarely described except in relationship with surgery of the abdominal aorta. The objective of this report is to describe the diagnostic approach including clinical, electrophysiological, imaging and cerebrospinal fluid criteria. With these methods 17 cases were diagnosed between 1982 and 1989, one related to surgery of the abdominal aorta. This series suggests that infarction of the spinal cord is a more common clinical entity than presently considered. Its rarity may be due to a high diagnostic threshold related to the perception that there is no specific therapy.