1106 - Delayed Onset Spinal Cord Ischemia with Incomplete Paraplegia Following Thoracic Aortic Aneurysm Repair

Case Diagnosis: C8 Asia C Spinal Cord Injury Due To Spinal Cord Ischemia

Case Description: An 81-year-old male was admitted to acute inpatient rehabilitation with one month of bilateral lower extremity (BLE) weakness after acute spinal cord ischemia. Six months prior, the patient underwent total arch replacement with an elephant trunk repair of a thoracic aortic aneurysm (TAA). Patient initially experienced debility post-surgery but eventually gained improvement in functional status. Five months post-surgery, he presented to the ED with chest and interscapular pain, and bilateral lower extremity weakness. Imaging of the spinal cord was consistent with microemboli through segmental arteries related to the endovascular graft. Upon rehabilitation admission, he reported BLE numbness/ paraplegia, urinary retention, and bowel incontinence, and was diagnosed with a C8 ASIA C spinal cord injury (SCI). Patient completed five weeks of acute inpatient rehabilitation and was discharged home with minor improvement in functional status.

Discussions: Delayed spinal cord ischemia after TAA repair is uncommon, as most cases occur within days to the first month after surgery, with delayed cases of several months rarely reported. Strategies exist for preventing SCI post-TAA repair perioperatively, which include elevating blood pressure and drainage of cerebrospinal fluid. However, there are few guidelines for surveillance, prevention, or management modalities for delayed cases other than monitoring for bilateral leg weakness and saddle sensory changes, especially since the measures used perioperatively are not practical nor advised for long-term prevention. Observational data suggest delayed-onset spinal cord ischemia may demonstrate improvement more often than immediate-onset, though most patients, regardless of onset, still never recover fully to baseline.

Conclusions: Delayed spinal cord ischemia is rare, unpredictable, and disabling. Perioperative surveillance does not address late events, and robust recovery data is sparse. Future investigation should focus on possible prevention measures, optimizing rehabilitation management, and improving outcomes for patients with delayed onset.