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Yoshitani K, Ogata S, Kato S, Tsukinaga A, Takatani T, Kin N, Ezaka M, Shimizu J, Furuichi Y, Uezono S, Kida K, Seo K, Kakumoto S, Miyawaki H, Kawamata M, Tanaka S, Kakinohana M, Izumi S, Uchino H, Kakinuma T, Nishiwaki K, Hasegawa K, Matsumoto M, Ishida K, Yamashita A, Yamakage M, Yoshikawa Y, Morimoto Y, Saito H, Goto T, Masubuchi T, Kawaguchi M, Tsubaki K, Mizobuchi S, Obata N, Inagaki Y, Funaki K, Ishiguro Y, Sanui M, Taniguchi K, Nishimura K, Ohnishi Y. Effect of cerebrospinal fluid drainage pressure in descending and thoracoabdominal aortic repair: a prospective multicenter observational study. J Anesth 2023; 37:408-415. [PMID: 36944824 DOI: 10.1007/s00540-023-03179-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/06/2023] [Indexed: 03/23/2023]
Abstract
PURPOSE Cerebrospinal fluid drainage (CSFD) is recommended during open or endovascular thoracic aortic repair. However, the incidence of CSFD complications is still high. Recently, CSF pressure has been kept high to avoid complications, but the efficacy of CSFD at higher pressures has not been confirmed. We hypothesize that CSFD at higher pressures is effective for preventing motor deficits. METHODS This prospective observational study included 14 hospitals that are members of the Japanese Society of Cardiovascular Anesthesiologists. Patients who underwent thoracic and thoracoabdominal aortic repair were divided into four groups: Group 1, CSF pressure around 10 mmHg; Group 2, CSF pressure around 15 mmHg; Group 3, CSFD initiated when motor evoked potential amplitudes decreased; and Group 4, no CSFD. We assessed the association between the CSFD group and motor deficits using mixed-effects logistic regression with a random intercept for the institution. RESULTS Of 1072 patients in the study, 84 patients (open surgery, 51; thoracic endovascular aortic repair, 33) had motor deficits at discharge. Groups 1 and 2 were not associated with motor deficits (Group 1, odds ratio (OR): 1.53, 95% confidence interval (95% CI): 0.71-3.29, p = 0.276; Group 2, OR: 1.73, 95% CI: 0.62-4.82) when compared with Group 4. Group 3 was significantly more prone to motor deficits than Group 4 (OR: 2.56, 95% CI: 1.27-5.17, p = 0.009). CONCLUSION CSFD is not associated with motor deficits in thoracic and thoracoabdominal aortic repair with CSF pressure around 10 or 15 mmHg.
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Affiliation(s)
- Kenji Yoshitani
- Department of Transfusion, National Cerebral and Cardiovascular Center, 6-1 Kishibeshimmachi, Suita, Osaka, 564-8565, Japan.
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Soshiro Ogata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Shinya Kato
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Akito Tsukinaga
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- Department of Anesthesiology, School of Medicine, Yokohama City University, Yokohama, Japan
| | - Tsunenori Takatani
- Division of Central Clinical Laboratory, Nara Medical University, Kashihara, Nara, Japan
| | - Nobuhide Kin
- Department of Anesthesia, New Tokyo Hospital, Matsudo, Japan
| | - Mariko Ezaka
- Department of Anesthesia, New Tokyo Hospital, Matsudo, Japan
| | - Jun Shimizu
- Department of Anesthesiology, Sakakibara Heart Institute, Futyu, Japan
| | - Yuko Furuichi
- Department of Anesthesiology, Sakakibara Heart Institute, Futyu, Japan
| | - Shoichi Uezono
- Department of Anesthesiology, The Jikei University School of Medicine, Minato-ku, Japan
| | - Kotaro Kida
- Department of Anesthesiology, The Jikei University School of Medicine, Minato-ku, Japan
| | - Katsuhiro Seo
- Department of Emergency, Kokura Memorial Hospital, Fukuoka, Japan
| | - Shinichi Kakumoto
- Department of Anesthesiology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Hiroshi Miyawaki
- Department of Anesthesiology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Mikito Kawamata
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoshi Tanaka
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Manabu Kakinohana
- Department of Anesthesiology, Faculty of Medicine, University of Ryukyu, Nishihara, Japan
| | - Shunsuke Izumi
- Department of Anesthesiology, Faculty of Medicine, University of Ryukyu, Nishihara, Japan
| | - Hiroyuki Uchino
- Department of Anesthesiology, Tokyo Medical University, Shinjuku-ku, Japan
| | - Takayasu Kakinuma
- Department of Anesthesiology, Tokyo Medical University, Shinjuku-ku, Japan
| | - Kimitoshi Nishiwaki
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuko Hasegawa
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mishiya Matsumoto
- Department of Anesthesiology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Kazuyoshi Ishida
- Department of Anesthesiology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Atsuo Yamashita
- Department of Anesthesiology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yusuke Yoshikawa
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yuji Morimoto
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hitoshi Saito
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takahisa Goto
- Department of Anesthesiology, School of Medicine, Yokohama City University, Yokohama, Japan
- Department of Anesthesiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Tetsuhito Masubuchi
- Department of Anesthesiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan
| | - Kosuke Tsubaki
- Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan
| | - Satoshi Mizobuchi
- Division of Anesthesiology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Norihiko Obata
- Division of Anesthesiology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshimi Inagaki
- Division of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Kazumi Funaki
- Division of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yoshiki Ishiguro
- Department of Anesthesiology, The Jikei University School of Medicine, Minato-ku, Japan
- Department of Anesthesiology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | | | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshihiko Ohnishi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Bhatia M, Kumar PA. Con: Lumbar Drains Should Routinely Be Placed by a Landmark Approach and Not by Fluoroscopic Guidance for Elective Thoracic Aortic Repairs. J Cardiothorac Vasc Anesth 2023; 37:183-186. [PMID: 36280577 DOI: 10.1053/j.jvca.2022.09.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/24/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Meena Bhatia
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
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Jónsson GG, Marklund N, Blennow K, Zetterberg H, Wanhainen A, Lindström D, Eriksson J, Mani K. Dynamics of Selected Biomarkers in Cerebrospinal Fluid During Complex Endovascular Aortic Repair - A Pilot Study. Ann Vasc Surg 2021; 78:141-151. [PMID: 34175417 DOI: 10.1016/j.avsg.2021.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Ischemic spinal cord injury (SCI) is a serious complication of complex aortic repair. Prophylactic cerebrospinal fluid (CSF) drainage, used to decrease lumbar cerebrospinal fluid (CSF) pressure, enables monitoring of CSF biomarkers that may aid in detecting impending SCI. We hypothesized that biomarkers, previously evaluated in traumatic SCI and brain injury, would be altered in CSF over time following complex endovascular aortic repair (cEVAR). OBJECTIVES To examine if a chosen cohort of CSF biomarker correlates to SCI and warrants further research. METHODS A prospective observational study on patients undergoing cEVAR with extensive aortic coverage. Vital parameters and CSF samples were collected on ten occasions during 72 hours post-surgery. A panel of ten biomarkers were analyzed (Neurofilament Light Polypeptide (NFL), Tau, Glial Fibrillary Acidic Protein (GFAP), Soluble Amyloid Precursos Protein (APP) α and β, Amyloid β 38, 40 and 42 (Aβ38, 40 and 42), Chitinase-3-like protein 1 (CHI3LI or YKL-40), Heart-type fatty acid binding protein (H-FABP).). RESULTS Nine patients (mean age 69, 7 males) were included. Median total aortic coverage was 68% [33, 98]. One patient died during the 30-day post-operative period. After an initial stable phase for the first few postoperative hours, most biomarkers showed an upward trend compared with baseline in all patients with >50% increase in value for NFL in 5/9 patients, in 7/9 patients for Tau and in 5/9 patients for GFAP. One patient developed spinal cord and supratentorial brain ischemia, confirmed with MRI. In this case, NF-L, GFAP and tau were markedly elevated compared with non-SCI patients (maximum increase compared with baseline in the SCI patient versus mean value of the maximal increase for all other patients: NF-L 367% vs 79%%, GFAP 95608% versus 3433%, tau 1020% vs 192%). CONCLUSION This study suggests an increase in all ten studied CSF biomarkers after coverage of spinal arteries during endovascular aortic repair. However, the pilot study was not able to establish a specific correlation between spinal fluid biomarker elevation and clinical symptoms of SCI due to small sample size and event rate.
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Affiliation(s)
- Gísli Gunnar Jónsson
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.
| | - Niklas Marklund
- Department of Neuroscience, Section of Neurosurgery, Uppsala University and Uppsala University Hospital; Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Neurosurgery, Lund, Sweden
| | - Kaj Blennow
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK; UK Dementia Research Institute at UCL, London, UK
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Surgical and Perioperative Sciences, Umeå University, Sweden
| | - David Lindström
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Jacob Eriksson
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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Oftadeh M, Ural N, LeVan P, Prabhu V, Haske M. The Evolution and Future of Spinal Drain for Thoracic Aortic Aneurysm Repair: A Review. J Cardiothorac Vasc Anesth 2021; 35:3362-3373. [PMID: 34154920 DOI: 10.1053/j.jvca.2021.04.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 11/11/2022]
Abstract
For decades, spinal drains for cerebrospinal fluid (CSF) pressure monitoring and drainage have been used as adjuncts to protect against spinal cord injury resulting from thoracic aortic aneurysm repair. There are many different approaches to placement and management of CSF drains, with no true consensus on best practice. Furthermore, the incidence of complications resulting from spinal drains largely has been stagnant. This review describes the history and rationale behind placement of CSF drains, explore various considerations, techniques, and equipment, and discuss potential considerations for developing more comprehensive protocols.
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Affiliation(s)
- Mina Oftadeh
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL.
| | - Nil Ural
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL
| | - Pierre LeVan
- Department of Anesthesiology, Franciscan Health Olympia Fields, Olympia Fields, IL
| | - Vikram Prabhu
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL
| | - Michael Haske
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL
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Forman N, Sinskey J, Shalabi A. A Review of Middle Aortic Syndromes in Pediatric Patients. J Cardiothorac Vasc Anesth 2020; 34:1042-1050. [DOI: 10.1053/j.jvca.2019.07.130] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 07/09/2019] [Accepted: 07/12/2019] [Indexed: 01/04/2023]
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Argalious M, Trombetta C, Makarova N, Saasouh W, Rajan S. Simulation Versus Problem Based Learning for Cerebrospinal Drainage Catheter Insertion and Management: A Randomized Trial in a Large Academic Anesthesiology Residency Program. J Cardiothorac Vasc Anesth 2019; 33:993-1000. [DOI: 10.1053/j.jvca.2018.07.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Indexed: 11/11/2022]
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Delgado-López PD, Garcés-Pérez G, García-Carrasco J, Alonso-García E, Gómez-Menéndez AI, Martín-Alonso J. Posterior Reversible Encephalopathy Syndrome with Status Epilepticus Following Surgery for Lumbar Stenosis and Spondylolisthesis. World Neurosurg 2018; 116:309-315. [PMID: 29864559 DOI: 10.1016/j.wneu.2018.05.174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 05/23/2018] [Accepted: 05/24/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic condition encountered in many different clinical settings; it generally occurs in the context of hypertensive crisis, immunosuppressive therapy, or autoimmune diseases. It is characterized by headache, stupor, seizures, and visual alterations. Magnetic resonance imaging findings include white matter changes preferentially in the parieto-occipital regions. Although pathogenesis is not fully elucidated, vasoconstriction and brain hypoperfusion seem to be the cause of brain ischemia and vasogenic edema. Cerebrospinal fluid hypotension is also a reported plausible pathogenic mechanism. CASE DESCRIPTION We present a case of PRES following laminectomy and fixation for L4-5 lumbar stenosis and spondylolisthesis. The patient presented with status epilepticus immediately after surgery that lasted 5 days. Brain magnetic resonance imaging showed fluid attenuated inversion recovery and T2 hyperintensities in the bilateral parietal and occipital lobes and external capsules. On the basis of postoperative lumbar images, we hypothesized that an unnoticed cerebrospinal fluid leak might have contributed to development of PRES. The patient developed multiple postoperative complications but ultimately recovered after treatment for severe hypertension and seizures. CONCLUSIONS Prompt recognition and treatment of this potentially life-threatening syndrome is necessary to increase the likelihood of favorable outcome. Spinal surgeons need to be aware of the possibility of neurologic deterioration after spinal surgery and be alert about the occurrence of a dural leak, either recognized or unnoticed, as the plausible mechanism triggering PRES.
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Affiliation(s)
| | - Gloria Garcés-Pérez
- Department of Anesthesiology, Hospital Universitario de Burgos, Burgos, Spain
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Godet G, Bertrand M, Fléron MH, Goarin JP, Colson P, Cardon A, Koskas F, Verhoye JP, Kieffer E. Cerebrospinal fluid drainage and thoracic endovascular aneurysm repair. Asian Cardiovasc Thorac Ann 2017; 25:608-617. [DOI: 10.1177/0218492317739472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Spinal cord complications including paraplegia and partial neurologic deficits remain a frequent problem during repair of descending thoracic or thoracoabdominal aortic aneurysms. Effective prevention of this dreaded complication is of paramount importance. Among the many adjuncts that have been proposed to prevent spinal cord complications, spinal fluid drainage is one that has been used by numerous teams. The aim of this review is to answer the following question: does spinal fluid drainage afford spinal cord protection during both open and endovascular repair of thoracic or thoracoabdominal aortic aneurysms?
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Affiliation(s)
- Gilles Godet
- Department of Anesthesiology and Intensive Care, and Vascular Surgery Unit, Pontchaillou University Hospital, Rennes, France
| | - Michèle Bertrand
- Department of Anesthesiology and Intensive Care, and Vascular Surgery Unit, Pitié Salpétrière University Hospital, Paris, France
| | - Marie-Hélène Fléron
- Department of Anesthesiology and Intensive Care, and Vascular Surgery Unit, Pitié Salpétrière University Hospital, Paris, France
| | - Jean-Pierre Goarin
- Department of Anesthesiology and Intensive Care, and Vascular Surgery Unit, Pitié Salpétrière University Hospital, Paris, France
| | - Pascal Colson
- Department of Anesthesiology and Intensive Care, Arnaud de Villeneuve University Hospital, Montpellier, France
| | - Alain Cardon
- Department of Cardiovascular and Thoracic Surgery, Pontchaillou University Hospital, Rennes, France
| | - Fabien Koskas
- Department of Vascular Surgery, Pitié Salpétrière University Hospital, Paris, France
| | - Jean-Philippe Verhoye
- Department of Cardiovascular and Thoracic Surgery, Pontchaillou University Hospital, Rennes, France
| | - Edouard Kieffer
- Department of Vascular Surgery, Pitié Salpétrière University Hospital, Paris, France
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McVey MJ, Farlinger CM, Van Arsdell G, Armstrong D, Holtby H. Anesthesia for Complex Cardiovascular Surgery in a Patient With PHACES Syndrome and Review of the Literature. J Cardiothorac Vasc Anesth 2017; 31:1042-1047. [DOI: 10.1053/j.jvca.2016.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Indexed: 12/19/2022]
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Shields LBE, Johnson JR, Shields CB. Posterior reversible encephalopathy syndrome following a thoracic discectomy–induced dural leak: case report. J Neurosurg Spine 2016; 25:586-590. [DOI: 10.3171/2016.4.spine1623] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by headaches, altered mental status, seizures, and visual disturbances. Classic MRI findings include white matter changes of the parieto-occipital regions. This syndrome has been encountered in myriad medical illnesses, including hypertension, preeclampsia/eclampsia, and immunosuppressive conditions. While the pathogenesis of the disorder is unclear, vasoconstriction and hypoperfusion leading to brain ischemia and vasogenic edema have been implicated as potential mechanisms. The authors present, to the best of their knowledge, the first case of PRES following a thoracic spinal surgery–induced dural leak noted on resection of the fifth rib during a thoracotomy for a T4–5 discectomy. Brain MRI revealed large areas of increased FLAIR and T2 hyperintensity in the superior posterior frontal lobes, superior and medial parietal lobes, and bilateral occipital lobes. Following repair of the CSF leak, the patient's symptoms resolved. Spinal surgeons should be alert to the potentially life-threatening condition of PRES, especially in a hypertensive patient who experiences surgery-induced dural leakage. The development of a severe positional headache with neurological signs is a red flag that suggests the presence of PRES. Prompt attention to the diagnosis and treatment of this condition by repairing the dural leak via surgery or expeditious blood patch increases the likelihood of a favorable outcome.
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Affiliation(s)
| | | | - Christopher B. Shields
- 1Norton Neuroscience Institute,
- 2Norton Healthcare; and
- 3Department of Anatomical Science and Neurobiology, University of Louisville, School of Medicine, Louisville, Kentucky
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Lindsay H, Srinivas C, Djaiani G. Neuroprotection during aortic surgery. Best Pract Res Clin Anaesthesiol 2016; 30:283-303. [DOI: 10.1016/j.bpa.2016.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 04/21/2016] [Accepted: 05/09/2016] [Indexed: 01/16/2023]
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Gerstein NS, Panikkath PV, Carlson AP, Pollock DM, Tayler E, Augoustides JG. CASE 4—2016. J Cardiothorac Vasc Anesth 2016; 30:548-54. [DOI: 10.1053/j.jvca.2015.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Indexed: 01/16/2023]
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Jafarzadeh F, Bashir M, Yan T, Harrington D, Field ML, Kuduvalli M, Oo A, Desmond M. Setting up and utilizing a service for measuring perioperative transcranial motor evoked potentials during thoracoabdominal aortic surgery and thoracic endovascular repair. Interact Cardiovasc Thorac Surg 2014; 18:748-56. [PMID: 24603163 DOI: 10.1093/icvts/ivu036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Paraplegia is a complication that may occur following surgery or endovascular stenting of thoracic and thoracoabdominal aortic pathology. Measuring transcranial motor evoked potentials (tcMEPs) has been shown to provide a reliable measure of spinal cord function during such procedures allowing interventions to protect cord function. In the spirit of sharing experience and eliminating the learning curve for others, this manuscript describes our experience of setting up a service for tcMEP monitoring as well as the documents and algorithms for measuring, recording and acting on the patient data, the so-called 'MEP Pathway'. METHODS Recording and interpretation of tcMEP during thoracoabdominal aortic intervention requires training of staff and close team working in the operating theatre and postoperative intensive care unit. Providing consistent, reliable, specific and sensitive information on spinal cord function and its safe and effective use to alter patient outcomes requires a protocol. The MEP pathway was developed by medical and paramedical staff at our institution based on clinical experience and literature reviews over a 1-year period (2012-2013). RESULTS The tcMEP pathway comprises six documents that guide staff in: (a) assessing suitability of patients, (b) setting up hardware, (c) preparing algorithms for management, (d) documenting intervention (left heart bypass, cardiopulmonary bypass or endovascular stenting) as well as (e) documenting postoperative intensive care processes. CONCLUSIONS The tcMEP pathway acts as a guide for safe introduction and use of tcMEPs in thoracoabdominal aortic interventions. tcMEP-led guidance of intraoperative and postoperative management in thoracic aortic surgery is an important adjunct in caring for this patient group.
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Affiliation(s)
- Fatemeh Jafarzadeh
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Mohamad Bashir
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Tristan Yan
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Deborah Harrington
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Mark L Field
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Manoj Kuduvalli
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Aung Oo
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Michael Desmond
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
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Jafarzadeh F, Field ML, Harrington DK, Kuduvalli M, Oo A, Kendall J, Desmond M, Mills K. Novel application of acetazolamide to reduce cerebrospinal fluid production in patients undergoing thoracoabdominal aortic surgery. Interact Cardiovasc Thorac Surg 2013; 18:21-6. [PMID: 24130087 DOI: 10.1093/icvts/ivt384] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Paraplegia is a rare but devastating complication, which may follow thoracoabdominal aortic surgery. Many adjuncts have been developed to reduce this risk including cerebrospinal fluid (CSF) drainage. Acetazolamide (carbonic anhydrase inhibitor) is a drug used to counteract mountain sickness and one of its effects is to reduce CSF production. Here, we report its first postoperative application in thoracoabdominal surgery with the aim of reducing cerebrospinal cord perfusion pressure and reducing risk of paraplegia. METHODS We retrospectively reviewed 6 patients who have been treated with this drug between 2011 and 2012 who were undergoing thoracoabdominal aortic surgery. Our indications were decided to include: (i) patients in whom a spinal drain could not be positioned; (ii) patients with blood-stained CSF; (iii) patients in whom the volume of CSF drained was outside guidelines; (iv) patients in whom CSF pressure was elevated; (v) patients with excessive vasopressor usage and (vi) patients with postoperative neurological dysfunction as measured by motor-evoked potentials or clinical examination. All were given 500 mg intravenous acetazolamide, not more than eight hourly, for a duration dependent on response. RESULTS In the 6 patients, 2 received a single dose of the drug and responded by an immediate drop in intracranial pressure (ICP) pressure. Of the 4 who received multiple doses of the drug, 1 had an immediate decline in ICP after each of the first six doses, while 3 had no discernable response. CONCLUSIONS This is the first report of the efficacy of acetazolamide in reducing CSF production and lowering ICP during thoracoabdominal aortic surgery. We believe that its use will be beneficial in the 6 patient groups described. Our experience suggests there are 'responders' and 'non-responders', the characteristics of whom are yet to be defined. Its efficacy in reducing not just CSF volume and ICP but also clinically relevant morbidity such as paraplegia, is the subject of a planned randomized controlled trial. This report serves to raise awareness of the possible efficacy of this drug when normal management strategies are limited or exhausted.
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Affiliation(s)
- Fatemeh Jafarzadeh
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
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