Recovery from paraplegia following aortic saddle embolism. Case report

Abstract

An aortic saddle embolus causing paraplegia is rare and even rarer is a documentation of neurological recovery from this event. A 47 year old male presented with absent pulsations in the lower limbs and paraplegia, both of sudden onset. He underwent immediate bilateral transfemoral embolectomy.The postoperative period was stormy. The paraplegia recovered over a period of 2 months and he could walk to his place of work after 6 months. The rare combination of saddle embolus and paraplegia is discussed. An attempt has been made to verify the hypothesis of Dickson et al which states that a low origin of the great radicular artery (GRA) below TI2 level may be responsible for paraplegia when obstructed by a saddle embolus. We found the GRA arising at L2 vertebral level in this patient. Postoperative selective spinal arteriogram and magnetic resonance imaging (MRI) of the spinal cord showed a patent GRA and normal spinal cord structure respectively. Early surgical intervention in restoring the blood flow into the GRA may prevent severe histological changes hitherto responsible for nonrecovery from paraplegia in the earlier reports.

Rare Presentation of Acute Lower Limb Ischemia: Saddle Aortic Embolus with Paraplegia - Case Report

“…A case report by Chandrashekar et al described a similar patient who experienced a sudden onset of paraplegia due to a saddle embolus. The patient's paraplegia resolved over 2 months [9].…”

Caso clínico de interés: síndrome de Leriche

“…Posteriormente se planteó isquemia medular aguda que si bien es cierto puede presentarse de forma aislada, también existen casos reportados de isquemia medular aguda asociados con el SL y el conocimiento de esta relación nos acerca más al diagnóstico, porque la isquemia medular sí explica claramente los síntomas neurológicos de la paciente si se recuerda que parte de la irrigación de la médu-la espinal está dada por arterias intercostales bajas y lumbares a través de la arteria radicular magna para la médula toracolumbar (T8-L5), y arterias lumbares bajas, iliolumbares 7 y sacras laterales, ramas de las hipogástricas, para la cauda equina 16 . De tal modo que la oclusión infrarrenal de la aorta puede producir debilidad de extremidades inferiores por neuropatía isquémica de la cauda equina 16,17 como ocurrió en este caso. Finalmente y por la rápida evolución del cuadro clínico con ausencia de pulso, piel moteada y fría se planteó el diagnóstico de SL y se solicitó la angiotomografía aórtica siendo este el método diagnóstico más apropiado para confirmar la oclusión trombótica de la arteria aorta infrarrenal 3,10,14,18 .…”

Relationships Between AAA and Cauda Equina Syndrome

“…Hence the lumbosacral cord which, is mainly supplied by the singular artery of Adamkiewicz, is the most sensitive to hypoperfusion; possibly due to its greater metabolic demands (lumbosacral enlargement) [22,26] . A saddle embolus can cause occlusion of the GRA causing distal cord ischaemia [27] . The cauda equina is mainly supplied by lateral and medial sacral arteries, which arise from the internal iliac artery [27] .…”

“…A saddle embolus can cause occlusion of the GRA causing distal cord ischaemia [27] . The cauda equina is mainly supplied by lateral and medial sacral arteries, which arise from the internal iliac artery [27] . Spinal cord infarction presents with sudden onset of severe pain, radiating down the legs (radicular) [24] and progressive sensori-motor deficits in the initial stages.…”