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Intermittent Spinal Cord Ischemia
Nida Ahmed, MD, Carlos Bechara, MD, Carlos Bechara, MD.
Loyola University Medical Center, Maywood, IL, USA.

DEMOGRAPHICS
69 year old male with history of chronic type B aortic dissection, hypertension, hyperlipidemia and diabetes mellitus.
HISTORY
The patient had progressive aneurysmal degeneration of type B aortic dissection with the thoracic segment measuring 4.2cm and the infrarenal segment measuring 6.2cm.
PLAN
Patient was recommended to have a staged endovascular thoracoabdominal aneurysm repair with TEVAR followed by abdominal aortic repair with a fenestrated endograft. Patient underwent successful placement of a Cook Zenith Alpha thoracic endograft. The endograft extended from just distal to the left subclavian artery to approximately two centimeters proximal to the celiac artery. The patient had retrograde filling of the false lumen at the end of the procedure. No spinal drain was used. There were no changes on SSEP during the case. On POD#1 patient experienced crushing back pain and bilateral lower extremity paralysis. Patient had emergent spinal drain placement with complete resolution of paralysis. The spinal drain was clamped after 48 hours with no changes in motor exam. Approximately 24 hours later, the patient had a second episode of back pain followed by bilateral lower extremity paralysis after having a bowel movement. The spinal drain was unclamped. CT scan showed partial thrombosis of the false lumen and no spinal cord infarcts. Lower extremity strength gradually returned to new baseline of 4/5 right lower extremity strength and 3/5 left lower extremity strength. The patientís motor strength was waxing and waning and noted to related to episodes of Valsalva. Patient was started on aggressive bowel regimen. CSF pressure threshold for drainage was gradually increased daily to build spinal cord tolerance prior to drain removal on POD#11.
DISCUSSION
This is an unusual case of waxing and waning lower extremity paralysis due to spinal cord ischemia after TEVAR. The patient was expected to have adequate perfusion of the thoracic spine considering patent left subclavian artery, patent bilateral hypogastric artery and retrograde filling of the false lumen. Episodes of motor function decline after the initial resolution of paralysis were noted to be related temporally to bowel movements. This is suggestive of the fact that the patientís spinal cord pressure increased with the Valsalva maneuver. This was further supported by the fact that patientís motor exam stabilized after bowel regimen. We also used steroids in our management.


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