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Poster Sessions: Case Reports and Miscellaneous

Paraplegia after elective cardiac revascularization: case report: P-113

Filipescu, D.; Luchian, M.; Raileanu, I.; Cristea, M.; Ghenu, O.; Iliescu, V.; Rugina, M.; Tulbure, D.

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European Journal of Anaesthesiology: June 2005 - Volume 22 - Issue - p 44
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Introduction: Paraplegia after coronary artery bypass grafting (CABG) is an uncommon complication. The mechanisms of the spinal cord injury in this context are not clear. The outcome is unpredictable [1]. We present the case of a patient with postoperative paraplegia after elective CABG who fully recovered.

Case report: A 50-year-old white male with previous anterior myocardial infarction was admitted for elective CABG surgery. He had a recent (two months) history of interventional angioplasty and stenting of the left anterior descending artery (LAD). The present angiography showed intra-stent occlusion, significant stenosis of the circumflex artery and normal ventricular function. Laboratory work-up was within normal limits except for the presence of factor V Leiden. Two-vessel coronary bypass grafting using the left internal thoracic artery for LAD and reversed saphenous vein graft for the first marginal artery was uneventfully performed. The postoperative course was satisfactory for the first four hours. Thereafter he developed a hypertensive crisis followed by ischaemic changes in the right coronary artery (RCA) territory on ECG and, within minutes, cardiac arrest (electro-mechanic dissociation).

Surgical re-exploration was decided as an emergency, during cardiac resuscitation. No bypass graft dysfunction was found. RCA spasm was suspected and the patient was stabilized with diltiazem and moderate inotropic support. New angiography performed by the right femoral route showed moderate left ventricular dysfunction, inferior hypokinesia, functional grafts and normal RCA. After 24 hours the patient was alert and oriented and was successfully extubated.

Neurological examination revealed paraplegia with sensory deficit below T12. The deep tendon reflexes and the plantar reflexes were absent. Sphincters tone and reflexes were abolished. The patient left the ICU after 14 days. The rehabilitation was continued in a specialized clinic. At one month after surgery he recovered sphincters control and ambulation. Mild persistent lower limb spasticity persisted. At three months after surgery he was fully recovered.

Conclusions: This is the presentation of the rare neurological complication of paraplegia after CABG, in a patient with factor V Leiden trait and post-operative acute myocardial infarction with cardiac arrest, who fully recovered. The factors which could contribute to this clinical presentation were: post-operative hypertensive crisis, spinal hypoperfusion during cardiac resuscitation and dispersion of aortic atheroma associated with spinal microembolism during control angiography. The postoperative arterial thrombo-embolic risk in patients with factor V Leiden trait needs to be evaluated.

Reference:

1 Geyer TE, Naik MJ, Pillai R. Anterior spinal artery syndrome after elective coronary artery bypass grafting. Ann Thorac Surg 2002; 73: 1971-1973. Review.
© 2005 European Society of Anaesthesiology