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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 5  |  Page : 1128-1130

Acute spinal cord infarction after aortobifemoral bypass


Department of Radiology, Military Hospital of Tunis, Tunisia

Date of Web Publication6-Sep-2017

Correspondence Address:
Sami Kouki
Department of Radiology, Military Hospital of Tunis, 1008 Montfleury
Tunisia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_745_16

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How to cite this article:
Kouki S, Labben E, Abdallah NB. Acute spinal cord infarction after aortobifemoral bypass. Neurol India 2017;65:1128-30

How to cite this URL:
Kouki S, Labben E, Abdallah NB. Acute spinal cord infarction after aortobifemoral bypass. Neurol India [serial online] 2017 [cited 2019 Oct 22];65:1128-30. Available from: http://www.neurologyindia.com/text.asp?2017/65/5/1128/214084


Sir,

A 65-year old male patient with a history of aortoiliac occlusive disease underwent an aortobifemoral bypass using knitted dacron graft, resulting in a successful and patent vascular anastomosis. On the next day after surgery, he complained of progressive, bilateral flaccid paraplegia with bladder incontinence, and dissociated sensory loss below the thoracic (T) 7 level. Acute anterior spinal cord syndrome was thus suspected. Spinal magnetic resonance imaging (MRI) was performed on the second day after surgery. It confirmed the diagnosis of an anterior spinal cord infarct (ASCI), showing abnormal areas of high signal intensities on T2-weighted images affecting the anterior two-third of the spinal cord from T7 to L1 levels and a focal cord swelling at the same level [Figure 1]. A second MRI performed a week later showed a stable appearance of the T2-weighted spinal cord abnormalities and gadolinium enhancement, especially of the central gray matter [Figure 2]. The patient was treated with cerebrospinal fluid drainage, intravenous steroid therapy, and pharmacologic regulation of the blood pressure, in addition to the physical therapy. Clinical evaluation at the 5th month showed a mild improvement in his motor and sensory disturbances, as well as bladder dysfunction. The patient then lost his sight.
Figure 1: Spine MRI performed two days after the surgery. (a) The sagittal section of the MRI, T2-weighted imaging, revealed an abnormal increase in the signal intensity affecting the spinal cord from T7 to L1 levels with focal cord enlargement. (b) The axial section of the MRI, T2-weighted imaging, revealed high signal intensities in the anterior two-third of the spinal cord. Acute spinal cord infarction may be visualised as two rounded intramedullary high-intensity lesions, named the “owl's eye” appearance

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Figure 2: Spine MRI performed a week after the operation. The T1-weighted images (a) before and (b) after gadolinium administration showing spinal cord enhancement (arrow)

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Acute spinal cord infarction is still a threat after an infrarenal aortic surgery. It occurs infrequently but represents a major cause of mortality as well as neurologic complications.[1] Its incidence with the aortobifemoral bypass procedure ranges between 0 and 5%, with the risk being higher in emergency cases (1.4–2%) when compared to the elective cases (0.1–0.2%).[2] This complication may actually be far more frequent than has been reported in literature due to the difficulty in establishing the proper diagnosis. In fact, many potential factors contribute to the development of this situation including prolonged aortic clamping, interruption of the  Artery of Adamkiewicz More Details, postoperative hypotension, epidural analgesia, and atherosclerosis.[2] Delayed spinal cord ischemia (SCI) has been postulated to be caused by reperfusion, cord edema, and subsequent hypoperfusion of the spinal cord. Systemic hypotension resulting in cord hypoperfusion has also been implicated in the pathogenesis of spinal cord infarction. Clinical presentations are varied and depend on the site of the spinal cord lesion. The ischemic injuries to the spinal cord and lumbosacral roots or plexus are classified according to their location and extent.[3] Spinal MRI is the key examination performed for patients with spinal symptoms after aortic surgery. It may rule out treatable causes such as compression by a subdural or epidural hematoma, or disc herniation, and also helps in confirming the diagnosis of ASCI when performed at least 4 h after the onset of clinical symptoms pertaining to the spinal cord. Spinal cord ischemia has a predictable and a chronological course on repeated MRI scans, and the diagnosis is based on the typical sequential appearance of the abnormalities. MRI findings are usually normal in the acute phase, which in fact supports the diagnosis of an early infarction;[1] whereas, spinal cord edema and T2 high signal intensities, especially if located in the anterior two-thirds of the spinal cord, may be expected after 24–48 hours. Gadolinium enhancement appears subsequent to the onset of symptoms. Therefore, repeated imaging is recommended to detect the evolving MRI changes.

Diffusion-weighted imaging (DWI) may lead to an early detection of the spinal cord infarction as it reveals the acute episode of spinal cord ischemia. Thus, even when T2-weighted imaging is still unremarkable, diffusion restriction is often seen.[4] Thus, DWI represents the most important sequence for detecting cytotoxic edema in infarction; however, its application in spinal cord lesions has technical limitations. These include susceptibility artifacts due to haemorrhage, respiratory movements and small size of the spinal cord. There are only a few studies reporting the useful contribution of DWI in the spinal cord infarction imaging protocol.[4],[5],[6]

Acknowledgement

The patient has been treated by Pr Manaa at Military hospital of Tunis, Tunisia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Alblas CL, Bouvy WH, Lycklama À, Nijeholt GJ, Boiten J. Acute spinal-cord ischemia: Evolution of MRI findings. J Clin Neurol 2012;8:218-23.  Back to cited text no. 1
    
2.
Bavaria JE, Appoo JJ, Makaroun MS, Verter J, Yu ZF, Mitchell RS. Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: A multicenter comparative trial. J Thorac Cardiovasc Surg 2007;133:369-77.  Back to cited text no. 2
    
3.
Gloviczki P, Cross SA, Satanson AW, Carmichael SW, Bower TC, Pairolero PC, et al. Ischemic injury to the spinal cord or lumbosacral plexus after aorto-iliac reconstruction. Am J Surg 1991;162:131-6.  Back to cited text no. 3
    
4.
Thurnher MM, Bammer R. Diffusion-weighted magnetic resonance imaging of the spine and spinal cord. Semin Roentgenol 2006;41:294-311.  Back to cited text no. 4
    
5.
Küker W, Weller M, Klose U, Krapf H, Dichgans J, Nägele T. Diffusion-weighted MRI of spinal cord infarction-high resolution imaging and time course of diffusion abnormality. J Neurol 2004;251:818-24.  Back to cited text no. 5
    
6.
Loher TJ, Bassetti CL, Lövblad KO, Stepper FP, Sturzenegger M, Kiefer C, et al. Diffusion-weighted MRI in acute spinal cord ischaemia. Neuroradiology 2003;45:557-61.  Back to cited text no. 6
    


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