Aortic fenestration for chronic aortic dissection type B complicated by transient ischemic attacks of spinal cord
2006; Elsevier BV; Volume: 44; Issue: 1 Linguagem: Inglês
10.1016/j.jvs.2006.03.030
ISSN1097-6809
AutoresMaraya Altuwaijri, Konstantinos T. Delis, Terri J. Vrtiska, Jimmy R. Fulgham, Péter Gloviczki,
Tópico(s)Cardiac Structural Anomalies and Repair
ResumoSpinal cord injury is a rare complication in patients with aortic dissection. The extrinsic arterial supply to the spinal cord, diminishing caudally, often becomes critically dependent on the great radicular artery (GRA) of Adamkiewicz at the thoracolumbar spine. There are no prior reports of spinal injury or ischemia caused by chronic aortic dissection. We report on a 51-year-old patient with chronic type B dissection of the aorta from below the subclavian takeoff through the iliac arteries, presented with multiple episodes of transient (1 to 5 minutes) spinal ischemic attacks, entailing sudden loss of motor and sensory functions in both legs, with collapse of the patient on the ground. GRA imaging acquired with 64-channel computed tomography angiography enabled aortic fenestration from T11 to L1, performed with supraceliac aortic cross-clamping (T8 to L2) via thoracoabdominal access. We critically appraise the pertinent literature. Spinal cord injury is a rare complication in patients with aortic dissection. The extrinsic arterial supply to the spinal cord, diminishing caudally, often becomes critically dependent on the great radicular artery (GRA) of Adamkiewicz at the thoracolumbar spine. There are no prior reports of spinal injury or ischemia caused by chronic aortic dissection. We report on a 51-year-old patient with chronic type B dissection of the aorta from below the subclavian takeoff through the iliac arteries, presented with multiple episodes of transient (1 to 5 minutes) spinal ischemic attacks, entailing sudden loss of motor and sensory functions in both legs, with collapse of the patient on the ground. GRA imaging acquired with 64-channel computed tomography angiography enabled aortic fenestration from T11 to L1, performed with supraceliac aortic cross-clamping (T8 to L2) via thoracoabdominal access. We critically appraise the pertinent literature. Autopsy data suggest that aortic dissection is the most common cause of acute life-threatening aortic pathology,1Clouse W.D. Hallett Jr, J.W. Schaff H.V. Spittell P.C. Rowland C.M. Ilstrup D.M. et al.Acute aortic dissection population-based incidence compared with degenerative aortic aneurysm rupture.Mayo Clin Proc. 2004; 79: 176-180Abstract Full Text Full Text PDF PubMed Scopus (382) Google Scholar with an annual age- and sex-adjusted incidence of 3.5 per 100,000 (95% confidence interval [CI]: 2.4 to 4.6)1Clouse W.D. Hallett Jr, J.W. Schaff H.V. Spittell P.C. Rowland C.M. Ilstrup D.M. et al.Acute aortic dissection population-based incidence compared with degenerative aortic aneurysm rupture.Mayo Clin Proc. 2004; 79: 176-180Abstract Full Text Full Text PDF PubMed Scopus (382) Google Scholar and a 30-day mortality of up to 18%.2Hagan P.G. Nienaber C.A. Isselbacher E.M. Bruckman D. Karavite D.J. Russman P.L. et al.The International Registry of Acute Aortic Dissection (IRAD) new insights into an old disease.JAMA. 2000; 283: 897-903Crossref PubMed Scopus (2376) Google Scholar, 3Pretre R. Von Segesser L.K. Aortic dissection.Lancet. 1997; 349: 1461-1464Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar, 4Hsu R.B. Ho Y.L. Chen R.J. Wang S.S. Lin F.Y. Chu S.H. Outcome of medical and surgical treatment in patients with acute type B aortic dissection.Ann Thorac Surg. 2005; 79: 790-794Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar Ischemic complications may develop in patients with type B acute aortic dissection involving any branch of the descending thoracic and abdominal aorta.2Hagan P.G. Nienaber C.A. Isselbacher E.M. Bruckman D. Karavite D.J. Russman P.L. et al.The International Registry of Acute Aortic Dissection (IRAD) new insights into an old disease.JAMA. 2000; 283: 897-903Crossref PubMed Scopus (2376) Google Scholar, 3Pretre R. Von Segesser L.K. Aortic dissection.Lancet. 1997; 349: 1461-1464Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar, 4Hsu R.B. Ho Y.L. Chen R.J. Wang S.S. Lin F.Y. Chu S.H. Outcome of medical and surgical treatment in patients with acute type B aortic dissection.Ann Thorac Surg. 2005; 79: 790-794Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar Spinal infarction or ischemia have been reported as complication of acute aortic dissection due to impairment of its extrinsic supply5Weisman A.D. Adams R.D. The neurological complications of dissecting aortic aneurysm.Brain. 1944; 67: 6-92Crossref Scopus (69) Google Scholar, 6Waltimo O. Karli P. Aortic dissection and paraparesis.Eur Neurol. 1980; 19: 254-257Crossref PubMed Scopus (25) Google Scholar, 7Gerber O. Heyer E.J. Vieux U. Painless dissections of the aorta presenting as acute neurologic syndromes.Stroke. 1986; 17: 644-647Crossref PubMed Scopus (88) Google Scholar, 8Zull D.N. Cydulka R. Acute paraplegia a presenting manifestation of aortic dissection.Am J Med. 1988; 84: 765-770Abstract Full Text PDF PubMed Scopus (73) Google Scholar, 9Rosen S.A. Painless aortic dissection presenting as spinal cord ischemia.Ann Emerg Med. 1988; 17: 840-842Abstract Full Text PDF PubMed Scopus (54) Google Scholar, 10Tanaka T. Uemura K. Sugiura M. Ohishi H. Tomita M. Nagasaki F. et al.Transient paraplegia caused by acute aortic dissection—case report.Neurol Med Chir (Tokyo). 1990; 30: 54-58Crossref PubMed Scopus (16) Google Scholar, 11Holloway S.F. Fayad P.B. Kalb R.G. Guarnaccia J.B. Waxman S.G. Painless aortic dissection presenting as a progressive myelopathy.J Neurol Sci. 1993; 15;120: 141-144Abstract Full Text PDF Scopus (19) Google Scholar, 12Spittell P.C. Spittell Jr, J.A. Joyce J.W. Tajik A.J. Edwards W.D. Schaff H.V. et al.Clinical features and differential diagnosis of aortic dissection experience with 236 cases (1980 through 1990).Mayo Clin Proc. 1993; 68: 642-651Abstract Full Text Full Text PDF PubMed Scopus (415) Google Scholar, 13de Lacerda R.C. Andrea P.B. Machado Neto E. de Figueiredo C.B. Teixeira A.B. de Carvalho P.C. [Acute paraplegia. A rare complication of aortic dissection].Arq Bras Cardiol. 1998; 70: 275-278Crossref PubMed Google Scholar, 14Elefteriades J.A. Lovoulos C.J. Coady M.A. Tellides G. Kopf G.S. Rizzo J.A. Management of descending aortic dissection.Ann Thorac Surg. 1999; 67: 2002-2005Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar, 15Joo J.B. Cummings A.J. Acute thoracoabdominal aortic dissection presenting as painless, transient paralysis of the lower extremities a case report.J Emerg Med. 2000; 19: 333-337Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 16Inamasu J. Hori S. Yokoyama M. Funabiki T. Aoki K. Aikawa N. Paraplegia caused by painless acute aortic dissection.Spinal Cord. 2000; 38: 702-704Crossref PubMed Scopus (37) Google Scholar, 17Blacker D.J. Wijdicks E.F. Ramakrishna G. Resolution of severe paraplegia due to aortic dissection after CSF drainage.Neurology. 2003; 61: 142-143Crossref PubMed Scopus (17) Google Scholar, 18Ohmi M. Shibuya T. Kawamoto S. Shimizu M. Nakame T. Kurihara N. Spinal cord ischemia complicated with acute aortic dissection and intramural hematoma; report of two cases].Kyobu Geka. 2003; 56: 473-478PubMed Google Scholar, 19Ogun S.A. Adefuye B. Kolapo K.B. Osalusi B.S. Anterior spinal artery syndrome complicating aortic dissecting aneurysm case report.East Afr Med J. 2004; 81: 549-552Crossref PubMed Scopus (6) Google Scholar in the great radicular artery (GRA) of Adamkiewicz (Fig 1).2Hagan P.G. Nienaber C.A. Isselbacher E.M. Bruckman D. Karavite D.J. Russman P.L. et al.The International Registry of Acute Aortic Dissection (IRAD) new insights into an old disease.JAMA. 2000; 283: 897-903Crossref PubMed Scopus (2376) Google Scholar, 20Maruyama R. Kamishima T. Shiiya N. Asano T. Matsuzaki K. Miyasaka K. et al.MDCT scan visualizes the Adamkiewicz artery.Ann Thorac Surg. 2003; 76: 1308Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 21Yoshioka K. Niinuma H. Kawazoe K. Ehara S. Three-dimensional demonstration of the Adamkiewicz artery and its collateral supply with contrast-enhanced magnetic resonance angiography.Eur J Cardiothorac Surg. 2004; 26: 440-441Crossref PubMed Scopus (7) Google Scholar As awareness of the clinical significance of the extrinsic spinal circulation gains momentum,22Yamada N. Okita Y. Minatoya K. Tagusari O. Ando M. Takamiya M. et al.Preoperative demonstration of the Adamkiewicz artery by magnetic resonance angiography in patients with descending or thoracoabdominal aortic aneurysms.Eur J Cardiothorac Surg. 2000; 18: 104-111Crossref PubMed Scopus (71) Google Scholar, 23Nijenhuis R.J. Leiner T. Cornips E.M. Wilmink J.T. Jacobs M.J. van Engelshoven J.M. et al.Spinal cord feeding arteries at MR angiography for thoracoscopic spinal surgery feasibility study and implications for surgical approach.Radiology. 2004; 233: 541-547Crossref PubMed Scopus (58) Google Scholar minimally invasive or noninvasive imaging methods are emerging.24Flohr T. Stierstorfer K. Raupach R. Ulzheimer S. Bruder H. Performance evaluation of a 64-slice CT system with z-flying focal spot.Rofo. 2004; 176: 1803-1810Crossref PubMed Scopus (243) Google Scholar, 25Kudo K. Terae S. Asano T. Oka M. Kaneko K. Ushikoshi S. et al.Anterior spinal artery and artery of Adamkiewicz detected by using multi-detector row CT.AJNR Am J Neuroradiol. 2003; 24: 13-17PubMed Google Scholar There have been no reports to our knowledge on spinal ischemic events caused by stable type B chronic aortic dissection.6Waltimo O. Karli P. Aortic dissection and paraparesis.Eur Neurol. 1980; 19: 254-257Crossref PubMed Scopus (25) Google Scholar, 7Gerber O. Heyer E.J. Vieux U. Painless dissections of the aorta presenting as acute neurologic syndromes.Stroke. 1986; 17: 644-647Crossref PubMed Scopus (88) Google Scholar, 8Zull D.N. Cydulka R. Acute paraplegia a presenting manifestation of aortic dissection.Am J Med. 1988; 84: 765-770Abstract Full Text PDF PubMed Scopus (73) Google Scholar, 9Rosen S.A. Painless aortic dissection presenting as spinal cord ischemia.Ann Emerg Med. 1988; 17: 840-842Abstract Full Text PDF PubMed Scopus (54) Google Scholar, 10Tanaka T. Uemura K. Sugiura M. Ohishi H. Tomita M. Nagasaki F. et al.Transient paraplegia caused by acute aortic dissection—case report.Neurol Med Chir (Tokyo). 1990; 30: 54-58Crossref PubMed Scopus (16) Google Scholar, 11Holloway S.F. Fayad P.B. Kalb R.G. Guarnaccia J.B. Waxman S.G. Painless aortic dissection presenting as a progressive myelopathy.J Neurol Sci. 1993; 15;120: 141-144Abstract Full Text PDF Scopus (19) Google Scholar, 12Spittell P.C. Spittell Jr, J.A. Joyce J.W. Tajik A.J. Edwards W.D. Schaff H.V. et al.Clinical features and differential diagnosis of aortic dissection experience with 236 cases (1980 through 1990).Mayo Clin Proc. 1993; 68: 642-651Abstract Full Text Full Text PDF PubMed Scopus (415) Google Scholar, 13de Lacerda R.C. Andrea P.B. Machado Neto E. de Figueiredo C.B. Teixeira A.B. de Carvalho P.C. [Acute paraplegia. A rare complication of aortic dissection].Arq Bras Cardiol. 1998; 70: 275-278Crossref PubMed Google Scholar, 14Elefteriades J.A. Lovoulos C.J. Coady M.A. Tellides G. Kopf G.S. Rizzo J.A. Management of descending aortic dissection.Ann Thorac Surg. 1999; 67: 2002-2005Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar, 15Joo J.B. Cummings A.J. Acute thoracoabdominal aortic dissection presenting as painless, transient paralysis of the lower extremities a case report.J Emerg Med. 2000; 19: 333-337Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 16Inamasu J. Hori S. Yokoyama M. Funabiki T. Aoki K. Aikawa N. Paraplegia caused by painless acute aortic dissection.Spinal Cord. 2000; 38: 702-704Crossref PubMed Scopus (37) Google Scholar, 17Blacker D.J. Wijdicks E.F. Ramakrishna G. Resolution of severe paraplegia due to aortic dissection after CSF drainage.Neurology. 2003; 61: 142-143Crossref PubMed Scopus (17) Google Scholar, 18Ohmi M. Shibuya T. Kawamoto S. Shimizu M. Nakame T. Kurihara N. Spinal cord ischemia complicated with acute aortic dissection and intramural hematoma; report of two cases].Kyobu Geka. 2003; 56: 473-478PubMed Google Scholar, 19Ogun S.A. Adefuye B. Kolapo K.B. Osalusi B.S. Anterior spinal artery syndrome complicating aortic dissecting aneurysm case report.East Afr Med J. 2004; 81: 549-552Crossref PubMed Scopus (6) Google Scholar We report on a patient with type B chronic aortic dissection who had experienced multiple episodes of spinal transient ischemic attack (TIA). Selective views of the artery of Adamkiewicz with 64-channel computed tomography (CT) angiography enabled aortic fenestration, from T11 to L1, performed with supraceliac aortic cross-clamping (T8 to L2) via thoracoabdominal access. A comprehensive review of the pertinent literature is also presented. A 51-year-old woman with a chronic type B aortic dissection presented with a recent history of multiple episodes of cramping and burning pain in the hips associated with a sudden loss of the standing posture and collapse on the ground. A transient weakness and loss of sensation in both legs was invariably present. The episodes had occurred irregularly over the previous 3 months and were preceded by some physical activity. Recovery was brief (≤5 minutes). More recently, she experienced diffuse burning ache in her left leg. Medical history comprised controlled hypertension, smoking (ceased recently), gastric surgery for peptic ulcer disease (Roux-en-Y bypass), and total abdominal hysterectomy. She had intermittent episodes of chest pain and fatigue but denied myocardial infarction or cerebrovascular events. Physical examination revealed a regular pulse in the absence of cardiac murmurs and a full complement of supra- and infra-aortic pulses without bruits or thrills. There was no evidence of an abdominal aortic aneurysm. Focal weakness or sensory impairment of the upper and lower extremities was ruled out. Reflexes were normal. Cardiac evaluation including transthoracic echocardiography (ejection fraction, 65% to 70%) stress electrocardiography, and 99mTc-sestamibi perfusion imaging was unremarkable for ischemia. Triphasic waveforms were present in the infrainguinal arterial system and the resting pressure indices were 1.09 on the right and 1.07 on the left. There was no pressure differential between the left and right arms (right, 108/60; left, 106/58). A treadmill exercise challenge at 0.8 mph with 0% incline had to be aborted in 25 seconds as the patient developed severe leg weakness in the presence of peripheral pulses. On magnetic resonance imaging (MRI), the spinal cord was normal in signal and caliber throughout its extent; there was no evidence of demyelinating disease. Spondylosis at L3-4 was noted without nerve root compromise, associated with severe facet arthropathy at L5-S1. A 64-channel CT angiography (Somatom Sensation 64, Siemens Medical Solutions, Forchheim, Germany) of the thoracic and abdominal aorta and iliac arteries was performed with 140 mL of iodinated contrast material at 4 mL/s (Omnipaque 350, Nycomed Imaging, Oslo, Norway). Optimized imaging acquired in 27 seconds using a CARE bolus-tracking program (Siemens), a tube rotation time of 0.37 seconds and a 64- × 0.6-mm collimation in a single breath-hold revealed a type B aortic dissection from just below the left subclavian to the common iliac arteries. The intimal aortic dissection flap throughout the descending thoracic and abdominal aorta had a midsagittal orientation, the true lumen being to the patient’s right and the false lumen located on the patient’s left (Fig 2, A). A left lumbar artery originating near the posterior edge of the intimal aortic flap (L1 level) provided the dominant contribution to the artery of Adamkiewicz. The intercostal arteries took off from the false lumen. A prominent left lumbar artery, originating near the posterior edge of the intimal aortic flap (L1), appeared pivotal to the artery of Adamkiewicz (Fig 2, B-D). The celiac and the right renal artery arose from the true lumen (right aortic half), while the left renal, superior and inferior mesenteric arteries were perfused from the false lumen (left aortic half). Dissection stopped at the origin of the left common iliac artery but continued through most of the right common iliac artery. Multiplanar and volume-rendered three-dimensional (coronal, sagittal, and oblique) images were acquired by post-processing the archived sub-millimeter (0.6 mm) data. In a multidisciplinary approach, including vascular surgery, neurology, and radiology, the diagnosis of transient spinal ischemia caused by flow impairment was reached. In light of the intercostal arteries and the left lumbar (converging to the Adamkiewicz artery) artery22Yamada N. Okita Y. Minatoya K. Tagusari O. Ando M. Takamiya M. et al.Preoperative demonstration of the Adamkiewicz artery by magnetic resonance angiography in patients with descending or thoracoabdominal aortic aneurysms.Eur J Cardiothorac Surg. 2000; 18: 104-111Crossref PubMed Scopus (71) Google Scholar, 23Nijenhuis R.J. Leiner T. Cornips E.M. Wilmink J.T. Jacobs M.J. van Engelshoven J.M. et al.Spinal cord feeding arteries at MR angiography for thoracoscopic spinal surgery feasibility study and implications for surgical approach.Radiology. 2004; 233: 541-547Crossref PubMed Scopus (58) Google Scholar, 26Kieffer E. Fukui S. Chiras J. Koskas F. Bahnini A. Cormier E. Preoperative spinal cord arteriography in aneurysmal disease of the descending thoracic and thoracoabdominal aorta preliminary results in 45 patients.Ann Vasc Surg. 1989; 3: 34-46Abstract Full Text PDF PubMed Scopus (126) Google Scholar, 27Kieffer E. Fukui S. Chiras J. Koskas F. Bahnini A. Cormier E. Spinal cord arteriography a safe adjunct before descending thoracic or thoracoabdominal aortic aneurysmectomy.J Vasc Surg. 2002; 35: 262-268Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar, 28Wadouh F. Lindemann E.M. Arndt C.F. Hetzer R. Borst H.G. The arteria radicularis magna anterior as a decisive factor influencing spinal cord damage during aortic occlusion.J Thorac Cardiovasc Surg. 1984; 88: 1-10PubMed Google Scholar, 29Maliszewski M. Ladzinski P. Aleksandrowicz R. Majchrzak H. Bierzynska-Macyszyn G. Wolanska-Karut J. Occlusion of radicular arteries—reasons, consequences and anastomotic substitution pathways.Spinal Cord. 1999; 37: 710-716Crossref PubMed Scopus (12) Google Scholar originating from the false lumen of the dissected aorta, fenestration of the aortic intimal flap would significantly improve the spinal inflow. The proximity of the left lumbar artery to the posterior edge of the intimal flap raised a suspicion of intermittent mechanical obstruction of the artery orifice by intimal flailing, thus making the case for a targeted and optimally placed open aortic fenestration to decrease the pressure difference between the false lumen and true lumen by eliminating the flailing of the intimal flap. Under general endotracheal intubation and spinal cord drainage, access to the supraceliac aorta from T8 to L2 was gained via a thoracoabdominal incision placed at the eighth intercostal space, with dissection of the diaphragm crura. Aortic cross-clamping for 13 minutes at the T9 and L2 levels, including the celiac and superior mesenteric arteries encircled with vessel loops, enabled a 5-cm longitudinal aortotomy and access to the aortic intimal flap at the left lumbar artery orifice territory. The true lumen was entered. A 3-cm long segment of the thick intimal flap was excised to its posterior edge, thereby creating a single aortic lumen at levels T11 to L1, encompassing the left lumbar artery orifice (L1) territory. Uncompromised back bleeding from the intercostal arteries was noted. Inflow to the celiac and superior mesenteric arteries originating near the anterior edge of the aortic flap was also secured. The aortotomy was sutured closed with running a 3-0 Prolene suture (Ethicon, Summerville, NJ), aided by two strips of cotton felt, each superimposed on either aortic edge (Fig 3, A-D). The patient was extubated on postoperative day 1, and the spinal drain was removed within 24 hours of surgery. She was neurologically intact, with a serum creatinine concentration of 1.1 mg/dL. After an uneventful early recovery, she was discharged on postoperative day 5. Hypertension was controlled with diuretics and β-blockade, consistent with her preoperative medication. At the 6-month follow-up, with full ambulation and physical activity she has remained free of transient spinal ischemia. A literature review (Table I) revealed only 25 cases of spinal ischemia in patients with aortic dissection, all in an acute setting. Rosen9Rosen S.A. Painless aortic dissection presenting as spinal cord ischemia.Ann Emerg Med. 1988; 17: 840-842Abstract Full Text PDF PubMed Scopus (54) Google Scholar reported a 67-year-old woman with transient paraplegia as the initial manifestation of an acute aortic dissection in the absence of thoracic or abdominal pain. MRI revealed a type A aortic dissection from the aortic root through the arch and descending aorta. On abdominal ultrasound, an intimal flap at the region of the GRA was noted. Tanaka et al10Tanaka T. Uemura K. Sugiura M. Ohishi H. Tomita M. Nagasaki F. et al.Transient paraplegia caused by acute aortic dissection—case report.Neurol Med Chir (Tokyo). 1990; 30: 54-58Crossref PubMed Scopus (16) Google Scholar described the onset of acute aortic dissection in a 64-year-old man presenting with sudden transient paraplegia, severe back pain, and hypertension. Complete transverse myelopathy was noted at T9 level on CT scanning. Recovery was gained with conservative treatment. Acute thoracoabdominal aortic dissection presenting with sudden onset of bilateral lower extremity numbness was reported by Joo et al15Joo J.B. Cummings A.J. Acute thoracoabdominal aortic dissection presenting as painless, transient paralysis of the lower extremities a case report.J Emerg Med. 2000; 19: 333-337Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar in a 63-year-old woman. Aortic dissection extended from the descending thoracic aorta to the renal arteries on MRI and CT scanning. There was no associated back pain. Conservative management with control of hypertension achieved full recovery.Table IReported cases of spinal ischemia in patients with aortic dissectionAuthorDatePatient/AgeAD type or TAAAPresentationImaging/diagnosisTreatmentOutcomeWeisman et al5Weisman A.D. Adams R.D. The neurological complications of dissecting aortic aneurysm.Brain. 1944; 67: 6-92Crossref Scopus (69) Google Scholar194468 FAPulselessness, cyanosis, flaccid paraplegiaChest fluoroscopy, PostmortemMedical (palliation)DeathWaltimo et.al6Waltimo O. Karli P. Aortic dissection and paraparesis.Eur Neurol. 1980; 19: 254-257Crossref PubMed Scopus (25) Google Scholar198052 MAParaplegia, acute heart failureAngiographyMedicalDeath (MI)46 MBChest pain, paraparesisMedicalRecovery56 MBChest and back painSurgicalParaplegiaGerber et al7Gerber O. Heyer E.J. Vieux U. Painless dissections of the aorta presenting as acute neurologic syndromes.Stroke. 1986; 17: 644-647Crossref PubMed Scopus (88) Google Scholar198663 FAHemiplegia (Lt)AngiographyMedicalDeath69 FALOC, Hemiplegia (Lt)Death78 MTAAA I + ADLeg weakness, ischemia (Lt)AK amputationZull et al8Zull D.N. Cydulka R. Acute paraplegia a presenting manifestation of aortic dissection.Am J Med. 1988; 84: 765-770Abstract Full Text PDF PubMed Scopus (73) Google Scholar198863 FAChest pain, paraplegia in bothAutopsyMedicalDeath (cardiac tamponade)67 MARosen9Rosen S.A. Painless aortic dissection presenting as spinal cord ischemia.Ann Emerg Med. 1988; 17: 840-842Abstract Full Text PDF PubMed Scopus (54) Google Scholar198867 FAParaplegiaUltrasound, MRIMedical, refused interventionDeathTanaka et al10Tanaka T. Uemura K. Sugiura M. Ohishi H. Tomita M. Nagasaki F. et al.Transient paraplegia caused by acute aortic dissection—case report.Neurol Med Chir (Tokyo). 1990; 30: 54-58Crossref PubMed Scopus (16) Google Scholar199066 MBHypertension, transient paraplegiaCTAMedicalHolloway et al11Holloway S.F. Fayad P.B. Kalb R.G. Guarnaccia J.B. Waxman S.G. Painless aortic dissection presenting as a progressive myelopathy.J Neurol Sci. 1993; 15;120: 141-144Abstract Full Text PDF Scopus (19) Google Scholar199392 FAComplete transverse myelopathy, paraplegiaMRAMedicalDeathSpittell et al12Spittell P.C. Spittell Jr, J.A. Joyce J.W. Tajik A.J. Edwards W.D. Schaff H.V. et al.Clinical features and differential diagnosis of aortic dissection experience with 236 cases (1980 through 1990).Mayo Clin Proc. 1993; 68: 642-651Abstract Full Text Full Text PDF PubMed Scopus (415) Google Scholar19932 patientsBParaplegiaN/AN/AN/ALacerda et al13de Lacerda R.C. Andrea P.B. Machado Neto E. de Figueiredo C.B. Teixeira A.B. de Carvalho P.C. [Acute paraplegia. A rare complication of aortic dissection].Arq Bras Cardiol. 1998; 70: 275-278Crossref PubMed Google Scholar199867 FBParaplegia, monoplegia upper extremityCTMedicalDeath (cardiac tamponade)Elefteriades et al14Elefteriades J.A. Lovoulos C.J. Coady M.A. Tellides G. Kopf G.S. Rizzo J.A. Management of descending aortic dissection.Ann Thorac Surg. 1999; 67: 2002-2005Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar19995/100BParaplegia/paraparesisCTA, MRI, angiography, echocardiogramNot determinedJoo et al15Joo J.B. Cummings A.J. Acute thoracoabdominal aortic dissection presenting as painless, transient paralysis of the lower extremities a case report.J Emerg Med. 2000; 19: 333-337Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar200063 FBParaplegiaMRI, CTMedicalRecoveryInamasu et al16Inamasu J. Hori S. Yokoyama M. Funabiki T. Aoki K. Aikawa N. Paraplegia caused by painless acute aortic dissection.Spinal Cord. 2000; 38: 702-704Crossref PubMed Scopus (37) Google Scholar200050 MAParaparesisMRIMedicalBlacker et al17Blacker D.J. Wijdicks E.F. Ramakrishna G. Resolution of severe paraplegia due to aortic dissection after CSF drainage.Neurology. 2003; 61: 142-143Crossref PubMed Scopus (17) Google Scholar200366 FBParaplegiaMRIMedical and CSF drainage, stent graft repairRecoveryOhmi et al18Ohmi M. Shibuya T. Kawamoto S. Shimizu M. Nakame T. Kurihara N. Spinal cord ischemia complicated with acute aortic dissection and intramural hematoma; report of two cases].Kyobu Geka. 2003; 56: 473-478PubMed Google Scholar200355 MBParaplegiaMRIMedicalParaplegia39 MAortic intramural hematomaMedicalRecoveryOgun et al19Ogun S.A. Adefuye B. Kolapo K.B. Osalusi B.S. Anterior spinal artery syndrome complicating aortic dissecting aneurysm case report.East Afr Med J. 2004; 81: 549-552Crossref PubMed Scopus (6) Google Scholar200445 MBParaparesisChest x-ray, clinical diagnosisMedicalDeath (rupture)Present report200651 FChronic AParaparesisCTAOpen aortic fenestrationRecoveryAD, Aortic dissection; MI, myocardial infarction; TAAA, thoracoabdominal aortic aneurysm; AK, above knee; CT, computed tomography; CTA, computed tomographic angiography; MRI, magnetic resonance imaging; LOC, loss of consciousness; CSF, cerebrospinal fluid. Open table in a new tab AD, Aortic dissection; MI, myocardial infarction; TAAA, thoracoabdominal aortic aneurysm; AK, above knee; CT, computed tomography; CTA, computed tomographic angiography; MRI, magnetic resonance imaging; LOC, loss of consciousness; CSF, cerebrospinal fluid. In contrast to these reports, our patient had a known history of chronic aortoiliac type B aortic dissection but otherwise enjoyed an active lifestyle before the onset of transient spinal ischemia. The onset of her symptoms could not be attributable to a further extension of dissection caudally. However, a radial extension of the aortic dissection posteriorly might have compromised the inflow to the extrinsic circulation of the spinal cord, particularly at the thoracolumbar segment, which is most susceptible to ischemia.20Maruyama R. Kamishima T. Shiiya N. Asano T. Matsuzaki K. Miyasaka K. et al.MDCT scan visualizes the Adamkiewicz artery.Ann Thorac Surg. 2003; 76: 1308Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 21Yoshioka K. Niinuma H. Kawazoe K. Ehara S. Three-dimensional demonstration of the Adamkiewicz artery and its collateral supply with contrast-enhanced magnetic resonance angiography.Eur J Cardiothorac Surg. 2004; 26: 440-441Crossref PubMed Scopus (7) Google Scholar, 26Kieffer E. Fukui S. Chiras J. Koskas F. Bahnini A. Cormier E. Preoperative spinal cord arteriography in aneurysmal disease of the descending thoracic and thoracoabdominal aorta preliminary results in 45 patients.Ann Vasc Surg. 1989; 3: 34-46Abstract Full Text PDF PubMed Scopus (126) Google Scholar, 27Kieffer E. Fukui S. Chiras J. Koskas F. Bahnini A. Cormier E. Spinal cord arteriography a safe adjunct before descending thoracic or thoracoabdominal aortic aneurysmectomy.J Vasc Surg. 2002; 35: 262-268Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar, 28Wadouh F. Lindemann E.M. Arndt C.F. Hetzer R. Borst H.G. The arteria radicularis magna anterior as a decisive factor influencing spinal cord damage during aortic occlusion.J Thorac Cardiovasc Surg. 1984; 88: 1-10PubMed Google Scholar, 29Maliszewski M. Ladzinski P. Aleksandrowicz R. Majchrzak H. Bierzynska-Macyszyn G. Wolanska-Karut J. Occlusion of radicular arteries—reasons, consequences and anastomotic substitution pathways.Spinal Cord. 1999; 37: 710-716Crossref PubMed Scopus (12) Google Scholar, 30Cheshire W.P. Santos C.C. Massey E.W. Howard Jr, J.F. Spinal cord infarction etiology and outcome.Neurology. 1996; 47: 321-330Crossref PubMed Scopus (332) Google Scholar Our patient’s antihypertensive medication, comprising β-blockade and a diuretic, had not been altered nor had she experienced a cardiac event. The diagnosis of transient spinal ischemia was reached in a multidis
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