Intraoperative Changes in Cerebrospinal Fluid Gas Tensions Reflect Paraplegia During Thoracoabdominal Aortic Surgery

Abstract

Background:

In this study, gas tensions in cerebrospinal fluid (CSF) were prospectively evaluated as intraoperative markers for the detection of neurological deficits.

Methods:

Spinal fluid, serum, and heart lung machine (HLM) perfusate were monitored for gas tensions (po ₂/pCo ₂) and related parameters (pH, lactate, and glucose) during thoracoabdominal aortic repair and correlated with perioperative neurological examination and electrophysiological testing.

Results:

Forty-seven patients were assessed for the study, and 40 consecutive patients were finally included. The patients were divided into 3 groups: group A (23 patients, 57.5%): no clinical or laboratory signs of neurological damage; group B (14 patients, 35%) who developed subclinical deficits; and group C (3 patients, 7.5%) who had paraplegia. Significant intraoperative changes in CSF gas tensions were observed with postoperative paraplegia. Glucose ratio between serum and CSF showed higher variability in group C, confirming a damage of the blood–brain barrier (BBB).

Conclusion:

Major neurological damage is reflected by early changes in CSF gas tensions and glucose variability, suggesting damage of the BBB in these patients.

Keywords

thoracoabdominal aortic repair CSF drainage paraplegia

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References

Bisdas

Redwan

Wilhelmi

. Less-invasive perfusion techniques may improve outcome in thoracoabdominal aortic surgery. J Thorac Cardiovasc Surg. 2010;140(6):1319–1324.

Coselli

Bozinovski

LeMaire

. Open surgical repair of 2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg. 2007;83(2):862–864.

Jacobs

de Mol

Elenbaas

. Spinal cord blood supply in patients with thoracoabdominal aortic aneurysms. J Vasc Surg. 2002;35(1):30–37.

Jacobs

Meylaerts

de Mol

Kalkman

. Strategies to prevent neurologic deficit based on motor-evoked potentials in type I and II thoracoabdominal aortic aneurysm repair. J Vasc Surg. 1999;29(1):48–57.

Crawford

Svensson

Hess

. A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta. J Vasc Surg. 1991;13(1):36–45.

Etz

Luehr

Kari

. Paraplegia after extensive thoracic and thoracoabdominal aortic aneurysm repair: does critical spinal cord ischemia occur postoperatively? J Thorac Cardiovasc Surg. 2008;135(2):324–330.

Etz

Homann

Plestis

. Spinal cord perfusion after extensive segmental artery sacrifice: can paraplegia be prevented? Eur J Cardiothorac Surg. 2007;31(4):643–648.

Khaladj

Teebken

Hagl

. The role of cerebrospinal fluid S100 and lactate to predict clinically evident spinal cord ischaemia in thoraco-abdominal aortic surgery. Eur J Vasc Endovasc Surg. 2008;36(1):11–19.

van Dongen

ter Beek

Schepens

. The relationship between evoked potentials and measurements of S-100 protein in cerebrospinal fluid during and after thoracoabdominal aortic aneurysm surgery. J Vasc Surg. 1999;30(2):293–300.

10.

Coselli

Tsai

. Motor evoked potentials in thoracoabdominal aortic surgery: CON. Cardiol Clin. 2010;28(2):361–368.

11.

Crawford

Mizrahi

Hess

Coselli

Safi

Patel

. The impact of distal aortic perfusion and somatosensory evoked potential monitoring on prevention of paraplegia after aortic aneurysm operation. J Thorac Cardiovasc Surg. 1988;95(3):357–367.

12.

Gugino

Kraus

Heino

. Peripheral ischemia as a complicating factor during somatosensory and motor evoked potential monitoring of aortic surgery. J Cardiothorac Vasc Anesth. 1992;6(6):715–719.

13.

Jacobs

Mess

Mochtar

Nijenhuis

Statius van Eps

Schurink

. The value of motor evoked potentials in reducing paraplegia during thoracoabdominal aneurysm repair. J Vasc Surg. 2006;43(2):239–246.

14.

Stadlbauer

Salomonowitz

van der

Buchfelder

Ganslandt

. Insight into the patterns of cerebrospinal fluid flow in the human ventricular system using MR velocity mapping. Neuroimage. 2010;51(1):42–52.

15.

Ballabh

Braun

Nedergaard

. The blood-brain barrier: an overview: structure, regulation, and clinical implications. Neurobiol Dis. 2004;16(1):1–13.

16.

Griepp

. Spinal cord perfusion and protection during descending thoracic and thoracoabdominal aortic surgery: the collateral network concept. Ann Thorac Surg. 2007;83(2):865–869.

17.

Sharpe

Dennis

Nasim

. Dual antiplatelet therapy prior to carotid endarterectomy reduces post-operative embolisation and thromboembolic events: post-operative transcranial Doppler monitoring is now unnecessary. Eur J Vasc Endovasc Surg. 2010;40(2):162–167.

18.

Fareed

Rothwell

Mehta

Naylor

. Synchronous carotid endarterectomy and off-pump coronary bypass: an updated, systematic review of early outcomes. Eur J Vasc Endovasc Surg. 2009;37(4):375–378.

19.

Kamiya

Klima

Hagl

. Cerebral microembolization during antegrade selective cerebral perfusion. Ann Thorac Surg. 2006;81(2):519–521.

20.

Ulus

Hellberg

Ulus

Karacagil

. Alterations in cerebrospinal fluid PO(2), PCO(2), and pH measurements during and after experimental thoracic aortic cross-clamping. Ann Vasc Surg. 2009;23(1):122–127. doi:10.1016/j.avsg.2008.06.004.