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Tomoo Inoue, Hiroaki Shimizu, Hitoshi Okabe and Teiji Tominga

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Takumi Kajitani, Toshiki Endo, Tomoo Inoue, Kenichi Sato, Yasushi Matsumoto and Teiji Tominaga

The authors report the case of a 70-year-old woman with lumbar spinal epidural arteriovenous fistula (SEDAVF) who experienced subarachnoid hemorrhage (SAH) after a diagnostic lumbar puncture. According to the literature, perimedullary spinal vein enlargement is a hallmark of spinal vascular diseases; however, there are certain cases in which routine sagittal MRI fails to disclose signal flow voids. In such cases, patients may undergo a lumbar tap to investigate the possible causes of spinal inflammatory or demyelinating disease. Recognizing this phenomenon is essential because lumbar puncture of the epidural venous pouch or an enlarged intradural vein in SEDAVF may induce severe SAH. A high clinical index of suspicion can prevent similar cases in lumbar SEDAVF.

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Ahmed Mansour, Toshiki Endo, Tomoo Inoue, Kenichi Sato, Hidenori Endo, Miki Fujimura and Teiji Tominaga

The authors report the case of a 78-year-old man with a craniocervical junction epidural arteriovenous fistula who presented with subarachnoid hemorrhage from a ruptured anterior spinal artery (ASA) aneurysm. Because endovascular embolization was difficult, a posterolateral approach was chosen and a novel endoscopic fluorescence imaging system was utilized to clip the aneurysm. The fluorescence imaging system provided clear and magnified views of the ventral spinal cord simultaneously with the endoscope-integrated indocyanine green videoangiography, which helped safely obliterate the ASA aneurysm. With the aid of this novel imaging system, surgeons can appreciate and manipulate complex vascular pathologies of the ventral spinal cord through a posterolateral approach, even when the lesion is closely related to the ASA.

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William J. Readdy, William D. Whetstone, Adam R. Ferguson, Jason F. Talbott, Tomoo Inoue, Rajiv Saigal, Jacqueline C. Bresnahan, Michael S. Beattie, Jonathan Z. Pan, Geoffrey T. Manley and Sanjay S. Dhall

OBJECT

The optimal mean arterial pressure (MAP) for spinal cord perfusion after trauma remains unclear. Although there are published data on MAP goals after spinal cord injury (SCI), the specific blood pressure management for acute traumatic central cord syndrome (ATCCS) and the implications of these interventions have yet to be elucidated. Additionally, the complications of specific vasopressors have not been fully explored in this injury condition.

METHODS

The present study is a retrospective cohort analysis of 34 patients with ATCCS who received any vasopressor to maintain blood pressure above predetermined MAP goals at a single Level 1 trauma center. The collected variables were American Spinal Injury Association (ASIA) grades at admission and discharge, administered vasopressor and associated complications, other interventions and complications, and timing of surgery. The relationship between the 2 most common vasopressors—dopamine and phenylephrine—and complications within the cohort as a whole were explored, and again after stratification by age.

RESULTS

The mean age of the ATCCS patients was 62 years. Dopamine was the most commonly used primary vasopressor (91% of patients), followed by phenylephrine (65%). Vasopressors were administered to maintain MAP goals fora mean of 101 hours. Neurological status improved by a median of 1 ASIA grade in all patients, regardless of the choice of vasopressor. Sixty-four percent of surgical patients underwent decompression within 24 hours. There was no observed relationship between the timing of surgical intervention and the complication rate. Cardiogenic complications associated with vasopressor usage were notable in 68% of patients who received dopamine and 46% of patients who received phenylephrine. These differences were not statistically significant (OR with dopamine 2.50 [95% CI 0.82–7.78], p = 0.105). However, in the subgroup of patients > 55 years, dopamine produced statistically significant increases in the complication rates when compared with phenylephrine (83% vs 50% for dopamine and phenylephrine, respectively; OR with dopamine 5.0 [95% CI 0.99–25.34], p = 0.044).

CONCLUSIONS

Vasopressor usage in ATCCS patients is associated with complication rates that are similar to the reported literature for SCI. Dopamine was associated with a higher risk of complications in patients > 55 years. Given the increased incidence of ATCCS in older populations, determination of MAP goals and vasopressor administration should be carefully considered in these patients. While a randomized control trial on this topic may not be practical, a multiinstitutional prospective study for SCI that includes ATCCS patients as a subpopulation would be useful for examining MAP goals in this population.