[Prevention of spinal cord ischemia after cross-clamping of the thoracic aorta--monitoring of spinal cord perfusion pressure and somatosensory evoked potentials].
The pressure difference between the mean distal aortic pressure (MDAP) and the cerebrospinal fluid pressure (CSFP), defined as the spinal cord perfusion pressure (SCPP), as well as somatosensory evoked potentials (SEP) were monitored intraoperatively to detect and prevent intraoperative spinal cord ischemia in 24 patients who required cross-clamping of the descending thoracic aorta. A temporary axillo-femoral shunt, utilizing a 10 mm woven Dacron tube graft, was employed in 10 patients and partial cardiopulmonary bypass was employed in fourteen. Ischemic SEP changes were seen in six patients. Two patients, whose SCPPs were 32 and 35 mmHg, showed a complete loss of SEP and subsequently developed paraplegia. In the other four cases, increase of the MDAP and/or withdrawal of cerebrospinal fluid were performed to increase the SCPP to more than 60 mmHg when ischemic SEP changes occurred. The SEP gradually recovered in two of these cases. The ischemic SEP changes seen in one patient, who had the longest aortic cross-clamping time, (175 minutes) returned to normal immediately after unclamping. In another case, who had a thoracoabdominal aortic aneurysm, the intercostal arteries were reimplanted since the ischemic SEP changes did not revert. These four patients recovered without any neurological deficit. In the other 18 cases without ischemic SEP change, SCPP was kept at more than 40 mmHg during aortic cross-clamping. We conclude that the SCPP should be maintained at more than 40 mmHg during aortic occlusion, and increased to more than 60 mmHg when ischemic SEP changes occur, by increasing MDAP and/or withdrawing cerebrospinal fluid in order to prevent postoperative paraplegia.
Maeda
S
S
Miyamoto
T
T
Murata
H
H
Yamashita
K
K
Iwaoka
S
S
Yasuoka
T
T
Hara
Y
Y
Ueda
T
T
D000328:Adult; D000368:Aged; D001013:Aorta, Thoracic; D001794:Blood Pressure; D015170:Cerebrospinal Fluid Pressure; D003250:Constriction; D005073:Evoked Potentials, Somatosensory; D005260:Female; D006801:Humans; D007430:Intraoperative Care; D007431:Intraoperative Complications / Q000503:physiopathology / Q000517:prevention & control; D007511:Ischemia / Q000503:physiopathology / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic; D013116:Spinal Cord / Q000098:blood supply*