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CAT 17-02-2005

CAT 17-02-2005. N.M. Gosens. Why this topic. Patient with paraparesis and backpain as presenting sign of aortic dissection. Instituted therapy by vascular surgeon: CSF Fluid drainage. Second patient with thoracic pain and transient paraparesis. Theory.

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CAT 17-02-2005

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  1. CAT 17-02-2005 N.M. Gosens

  2. Why this topic • Patient with paraparesis and backpain as presenting sign of aortic dissection. • Instituted therapy by vascular surgeon: CSF Fluid drainage. • Second patient with thoracic pain and transient paraparesis.

  3. Theory • 1- aortic occlusion leads to increased blood volume in the upper body  increased venous bloodstasis along neuraxis  increase in CSF pressure  reduction of spinal perfusion pressure (arterial pressure minus CSF pressure).

  4. Theory 2 • Ischemia of the spinal cord  edema of the spinal cord  increased tissue resistance to bloodflow/ compartment syndrome with high CSF pressure  reduction of spinal perfusion pressure. • Primary reduction in bloodflow also present.

  5. PICO • Patient with damage of the spinal cord due to aortic dissection. • Intervention by means of CSF drainage. • Control patient with spinal cord damage without CSF drainage. • Outcome: neurologic deficit because of spinal cord lesion.

  6. PUBMED results • Aortic dissection AND spinal fluid • 19 hits • 2 case reports matching our patient • Other literature about perioperative CSF drainage as protection or treatment of DND (delayed neurological deficit after surgery for aortic surgery).

  7. Case report 1 • Killen et al 2000 • Man 57 years with a aortic dissection presenting with thoracic back pain. 8 hours after admission to the ICU progressive weakness of both legs 4/3. Sensory disturbances were absent. • Two hours after onset of CSF drainage and administration of naloxon pt started to recover. • Six hours: complete recovery. (draining for 3days)

  8. Case report 2 • Blacker, wijdicks, ramakrishna 2003 • Female 66 yr with extensive aortic dissection. • Day 6: exacerbation of lumbar pain, followed bij numbness of left foot progressing in three hours to paresis right leg grade 2-3, paralysis of left leg. Sensory level Th 12. • I.v. Methylprednisolon

  9. Case report 2 - continued • CSF drainage: unmeasurable pressure, 25 ml removed. • Within 2 hours sensory disturbances dissapeared. Mild paresis. Pt was standing unassisted the next day. • CSF drainage was continued for 30 hours.

  10. Perioperative data • 2 Retrospective cohort studies • 1 prospective cohort study • 1 prospective randomised trial • 1 treatment study DND (6pt), 1 case report • 2 perioperative studies with multiple variables *

  11. Perioperative studies 1 • J vasc Surg 1994 Safi et al. Abstract. • 45 ptn met CSF drainage en distal aortic perfusion compared with 112 previous pt without. Duration of draining ? • With draining 9%, without 31% ND P< 0,0034. C/ significant reduction of neurological deficit

  12. Perioperative studies 2 • Group A (61) CSF drain and naloxon, group B (49) not. • Neurologic Deficit: Group A 1of 61, Group B 11 of 49 P=0,001 C/ significant reduction of ND with CSF drainage and naloxon. • Acher et al, J Vasc Surg 1994. Abstract

  13. Perioperative studies 3 • Safi et al, Ann Surg 2003 • 741 pt CSFD (3 days postop.) and distal aortic perfusion. • 263 pt without the above. • Immediate Neurologic deficit: 18/741 (2,4%) versus 18/263 (6,8) P< 0,0009 C/ these adjuncts are safe and effective

  14. Crawford et al, J vasc Surg 1990 • 47pt CSFD, 52 controls • CSFD after anesthesia, removed at the end of operation. Pressure <10-<20. • Neurologic deficit in 14/46 CFSD (30%) and 17/52 controls (33%) P = 0,8. C/ CSFD not beneficial in preventing ND.

  15. Perioperative studies 5 • Ackerman, Traynelis, Neurosurgery 2002 • 6pt with DND 12-40hrs postop. • 4pt immediate CSFD – marked improvement • 2pt delayed CFSD – no improvement.

  16. Should CSFD be used in patients with paraparesis because of aortic dissection?

  17. Literature • Blacker, Wijdicks, Ramakrishna: resolution of severe paraplegia due to aortic dissection after CSFdrainage. Neurology 2003 (61) 142-143. • Killen et al: Reversal of spinal cord ischemia resulting from aortic dissection. J thorac Cardiovasc Surg 2000; 119:1049-52. • Safi et al: neurologic deficit in patients at high risk with thoracoabdominal aneurysms: the role of cerebrospinal fluid drainage and distal aortic perfusion. J Vasc Surg. 1994 20-3: 434-444. Abstract. • Acher et al. combined use of cerebral spinal fluid drainage and naloxone reduces the risk of paraplegia in thoracoabdominal aneurysm repair. J Vasc Surg. 1994 19-2: 236-246. • Safi et al. Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic aortic repair. Ann Surg 2003;238: 372-381. • Crawford et al. A prospective randomised study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta. J Vasc Surg 1990: 13:36-46. • Ackerman, Traynelis: Treatment of delayed onset neurological deficit after aortic surgery with lumbar cerebrospinal fluid drainage. Neurosurgery 51: 1414-1422, 2002.

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