Résumé
Spinal cord ischemia (SCI), a complication of acute aortic dissection, has no established treatment. Here, we report the successful management of three cases of acute type A aortic dissection (ATAAD) with SCI using a multidisciplinary approach. Case 1: A 55-year-old man presented with paraparesis due to ATAAD (non-communicating type), cardiac tamponade, and no loss of consciousness. He underwent emergency surgery for ascending aortic replacement. He awoke 3 h after the surgery; however, as his paralysis was not improved, we initiated multidisciplinary treatment with cerebrospinal drainage, continuous infusion of naloxone, and steroid pulse therapy. These treatments led to the complete resolution of his symptom; he was discharged on Day 32, with no neurological deficits. Case 2: A 50-year-old woman presented with complete paralysis of the left lower limb due to ATAAD (communicating type) but no loss of consciousness. She underwent emergency surgery for ascending aortic replacement. She awoke 2 h after the surgery; however, as her paralysis was not improved, multidisciplinary treatment with cerebrospinal drainage, continuous infusion of naloxone, and steroid pulse therapy were initiated, which led to partial resolution of the symptoms. She could walk with orthotics and was discharged on Day 57. Case 3: A 43-year-old man presented with paraparesis of the left lower limb due to ATAAD (non-communicating type). He was hemodynamically stable, with no loss of consciousness. The ATAAD was conservatively managed, and multidisciplinary treatment with cerebrospinal drainage, continuous infusion of naloxone, and steroid pulse therapy was administered. These therapies led to the complete resolution of his symptoms; he was discharged on Day 46, with no neurological deficits. Hence, for ATAAD with SCI, multidisciplinary treatment, including emergency surgery, is an important therapeutic strategy.
Résumé
We report a rare case of paraplegia after emergency total arch replacement for type A acute aortic dissection. A 52-year-old man was referred to our hospital for acute aortic dissection. Contrast-enhanced computed tomography showed a type A aortic dissection extending from the aortic root into the right iliac arteries. The true lumen of the descending and abdominal aorta was collapsed and blood flow to the right lower limb had decreased. Large entry and re-entry tears were revealed in the ascending and distal arch aorta, respectively. His preoperative consciousness was clear, hemodynamics were stable, and there was no evidence of paraplegia or paraparesis. Extracorporeal circulation was established by femoral artery and right atrium cannulation. Total arch replacement was performed under moderate hypothermic circulatory arrest (lowest bladder temperature : 21.9°C). The postoperative course was uneventful and he was extubated 6 h postoperatively. Postoperative hemodynamic parameters were stable, the mean blood pressure was maintained at around 70 mmHg, and limb movements were confirmed at that time. Although there was no abnormality of lower limb movement until the following morning, paraplegia occurred about 17 h after surgery. While maintaining a mean blood pressure of over 90 mmHg, urgent cerebrospinal drainage was immediately performed and combined with steroid treatment and a continuous infusion of naloxone. The neurological defect was resolved immediately after cerebrospinal drainage, and neurological function steadily improved through rehabilitation. He was discharged 20 days after surgery with no neurological defects. Late paraplegia after total replacement for type A acute aortic dissection is a rare complication. From our experience, it is suggested that early diagnosis and treatment are important for improving paraplegia.