Spinal Cord Blood Flow in Patients with Acute Spinal Cord Injuries

Gallagher, Mathew J.; Hogg, Florence Rosie Avila; Zoumprouli, Argyro; Papadopoulos, Marios C.; Saadoun, Samira

doi:10.1089/neu.2018.5961

Cited by 57 publications

(45 citation statements)

References 41 publications

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“…The concept of SCPP opt is clinically important because it suggests that not only hypoperfusion but also hyperperfusion at the injury site may be detrimental. Potential mechanisms of hyperperfusion-induced cord injury include cord swelling, cord hemorrhage, and a local steal phenomenon [22]. sPRx versus SCPP plots for individual patients, rather than pooled patient data, yield SCPP opt values that differ markedly, by up to 60 mmHg, between patients [23].…”

Section: Optimum Scppmentioning

confidence: 99%

“…Advanced MRI techniques are limited largely due to artifacts from cardiorespiratory motion as well as signal loss from the bone and the metalwork used to stabilize the spine. In a recent study, we investigated SCBF intraoperatively using laser speckle contrast imaging, a noninvasive technique in which a laser beam penetrates through the dorsal theca, 2-3 mm deep into the spinal cord, thus imaging blood flow in the dorsal columns [22]. We discovered 3 SCBF patterns, characterized by distinct injury site metabolic signatures: necrosis-penumbra, hyperperfusion, and patchy perfusion (Fig.…”

Section: Spinal Cord Blood Flowmentioning

confidence: 99%

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Targeted Perfusion Therapy in Spinal Cord Trauma

Saadoun

Papadopoulos

2020

Neurotherapeutics

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We review state-of-the-art monitoring techniques for acute, severe traumatic spinal cord injury (TSCI) to facilitate targeted perfusion of the injured cord rather than applying universal mean arterial pressure targets. Key concepts are discussed such as intraspinal pressure and spinal cord perfusion pressure (SCPP) at the injury site, respectively, analogous to intracranial pressure and cerebral perfusion pressure for traumatic brain injury. The concept of spinal cord autoregulation is introduced and quantified using spinal pressure reactivity index (sPRx), which is analogous to pressure reactivity index for traumatic brain injury. The Ushaped relationship between sPRx and SCPP defines the optimum SCPP as the SCPP that minimizes sPRx (i.e., maximizes autoregulation), and suggests that not only ischemia but also hyperemia at the injury site may be detrimental. The observation that optimum SCPP varies between patients and temporally in each patient supports individualized management. We discuss multimodality monitoring, which revealed strong correlations between SCPP and injury site metabolism (tissue glucose, lactate, pyruvate, glutamate, glycerol), monitored by surface microdialysis. Evidence is presented that the dura is a major, but unappreciated, cause of spinal cord compression after TSCI; we thus propose expansion duroplasty as a novel treatment. Monitoring spinal cord blood flow at the injury site has revealed novel phenomena, e.g., 3 distinct blood flow patterns, local steal, and diastolic ischemia. We conclude that monitoring from the injured spinal cord in the intensive care unit is a safe technique that appears to enable optimized and individualized spinal cord perfusion.

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Section: Optimum Scppmentioning

confidence: 99%

Section: Spinal Cord Blood Flowmentioning

confidence: 99%

Targeted Perfusion Therapy in Spinal Cord Trauma

Saadoun

Papadopoulos

2020

Neurotherapeutics

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“…7,[11][12][13] Compression of the spinal cord against an unyielding spinal canal results in increased intraspinal pressure and reduced perfusion pressure, further jeopardizing blood flow to the spinal cord. [14][15][16] In motor complete TSCI patients, swelling of the spinal cord spreads rostrally and caudally from the injury epicenter in fusiform fashion, 8 at a rate of *900 lm/h. 13,17 Frequently, by the time the victim is transferred to the trauma center, intramedullary lesion length (IMLL), can measure between 40 and 100 mm in length, far beyond the cross-sectional injury epicenter.…”

Section: Introductionmentioning

confidence: 99%

Efficacy of Ultra-Early (< 12 h), Early (12–24 h), and Late (>24–138.5 h) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades A, B, and C Cervical Spinal Cord Injury

Aarabi

Akhtar–Danesh

Chryssikos

et al. 2020

Journal of Neurotrauma

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In cervical traumatic spinal cord injury (TSCI), the therapeutic effect of timing of surgery on neurological recovery remains uncertain. Additionally, the relationship between extent of decompression, imaging biomarker evidence of injury severity, and outcome is incompletely understood. We investigated the effect of timing of decompression on long-term neurological outcome in patients with complete spinal cord decompression confirmed on postoperative magnetic resonance imaging (MRI). American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade conversion was determined in 72 AIS grades A, B, and C patients 6 months after confirmed decompression. Thirty-two patients underwent decompressive surgery ultra-early (< 12 h), 25 underwent decompressive surgery early (12-24 h), and 15 underwent decompressive surgery late (> 24-138.5 h) after injury. Age, gender, injury mechanism, intramedullary lesion length (IMLL) on MRI, admission ASIA motor score, and surgical technique were not statistically different among groups. Motor complete patients (p = 0.009) and those with fracture dislocations (p = 0.01) tended to be operated on earlier. Improvement of one grade or more was present in 55.6% of AIS grade A, 60.9% of AIS grade B, and 86.4% of AIS grade C patients. Admission AIS motor score (p = 0.0004) and pre-operative IMLL (p = 0.00001) were the strongest predictors of neurological outcome. AIS grade improvement occurred in 65.6%, 60%, and 80% of patients who underwent decompression ultra-early, early, and late, respectively (p = 0.424). Multiple regression analysis revealed that IMLL was the only significant variable predictive of AIS grade conversion to a better grade (odds ratio, 0.908; confidence interval [CI], 0.862-0.957; p < 0.001). We conclude that in patients with post-operative MRI confirmation of complete decompression following cervical TSCI, pre-operative IMLL, not the timing of surgery, determines long-term neurological outcome.

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“…In contrast, NE did not modify SCBF and worsened hemorrhaging, mirroring observations from Soubeyrand et al 4 in a feline model. Several studies have linked NE with central gray matter hemorrhaging in experimental models 5,6 , which is thought to result from unfavourable blood flow redistribution in the cord microenvironment 3 . Specifically, NE may reduce flow in the intact cord circulation via α 2 -mediated vasoconstriction 20,21 and subsequently worsen blood loss and hemorrhage through the damaged microvasculature.…”

Section: Discussionmentioning

confidence: 99%

“…Hemodynamic management is one of the only neuroprotective strategies available to clinicians, and current guidelines suggest that mean arterial pressure (MAP) be maintained between 85-90 mmHg with intravenous fluids and vasopressors such as norepinephrine (NE), with the aim of offsetting systemic hypotension and maintaining adequate spinal cord perfusion 2 . Though this “one-size-fits-all” strategy can improve spinal cord blood flow (SCBF), vasopressor management with NE has been shown to produce potentially harmful SCBF profiles in some acute SCI patients 3 and has been shown by multiple investigators to exacerbate intraparenchymal hemorrhage 4–6 . In the setting of acute SCI, clinical studies have shown strong associations between increased cord hemorrhaging and worsened neurological outcomes (i.e.…”

Section: Introductionmentioning

confidence: 99%

Cardio-centric hemodynamic management improves spinal cord oxygenation and mitigates hemorrhage in acute spinal cord injury

Williams

Manouchehri

Erskine

et al. 2020

Preprint

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21Chronic high-thoracic and cervical spinal cord injury (SCI) results in a complex phenotype of 22 cardiovascular consequences, including impaired left-ventricular contractility. Here, we sought to 23 determine whether such dysfunction manifests immediately post-injury, and if so, whether 24 correcting impaired contractility can improve spinal cord oxygenation (SCO2), blood flow (SCBF) 25 and metabolism. Using a porcine model of SCI, we demonstrate that high-thoracic SCI acutely 26 impairs cardiac contractility and causes substantial reductions in intraparenchymal SCO2 and 27 SCBF within the first hours post-injury. Utilizing the same model, we next show that treating the 28 reduced contractile function with the b-agonist dobutamine is more efficacious at increasing SCO2 29 and SCBF than the current clinical standard of vasopressor therapy, whilst also mitigating 30 increased anaerobic metabolism and hemorrhage in the injured cord. Our data provide compelling 31 evidence that cardio-centric hemodynamic management represents a novel and advantageous 32 alternative to the current clinical standard of vasopressor therapy for acute traumatic SCI. 33

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Spinal Cord Blood Flow in Patients with Acute Spinal Cord Injuries

Cited by 57 publications

References 41 publications

Targeted Perfusion Therapy in Spinal Cord Trauma

Targeted Perfusion Therapy in Spinal Cord Trauma

Efficacy of Ultra-Early (< 12 h), Early (12–24 h), and Late (>24–138.5 h) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades A, B, and C Cervical Spinal Cord Injury

Cardio-centric hemodynamic management improves spinal cord oxygenation and mitigates hemorrhage in acute spinal cord injury

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