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BACKGROUND: Cardiovascular autonomic dysfunction is a relatively common secondary complication of tetraplegia. In addition to low baseline arterial blood pressure, tetraplegics can develop sudden-onset hypertensive episodes associated with a variety of symptoms and signs (so-called autonomic dysreflexia). Unfortunately, this potentially life-threatening medical entity is often overlooked and mismanaged. With this, a case of typical presentation of autonomic dysreflexia in an individual with acute severe cervical spinal cord impairment due to neuromyelitis optica (NMO) is reported and discussed. CASE REPORT: A 60-year-old, Asian woman developed a rapidly progressive tetraplegia associated with neurogenic bladder and bowel, and cardiovascular autonomic dysfunction due to NMO. In addition to low baseline blood pressure and orthostatic hypotension, the patient developed episodes of autonomic dysreflexia during the acute stage following C2 motor complete tetraplegia. The episodes of autonomic dysreflexia resolved after fecal disimpaction. Her blood pressure stabilized after fecal disimpaction, even though occasional, milder episodes of autonomic dysreflexia occurred during bowel routines in the acute and subacute stages after tetraplegia. Her cardiovascular function normalized as she also regained motor and sensory function in the chronic stage after initial flare of NMO. CONCLUSIONS: This case report illustrates a clinically relevant, but still under-recognized cardiovascular autonomic complication of severe, cervical or high-thoracic spinal cord impairment due to NMO. In addition to low baseline blood pressure and orthostatic hypotension, the patient developed episodes of autonomic dysreflexia during the acute stage after tetraplegia. Autonomic dysreflexia requires early diagnosis and proper treatment in order to prevent severe complications or death. Greater awareness of this potentially life-threatening cardiovascular emergency of spinal cord impairment is needed among patients, caregivers, and healthcare professionals, including neurologists.

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Autonomic dysreflexia is a clinical emergency that occurs in individuals with spinal cord injury at level T-6 and above. We present a 58-year-old male patient with paraplegia who developed a severe, recurrent, throbbing headache during the night, which was relieved by emptying the urinary bladder by intermittent catheterisation. As this person continued to get episodes of severe headache for more than 6 months, computed tomography (CT) of the brain was performed. CT revealed an infarct measuring 1.2 cm in the right basal ganglia. In order to control involuntary detrusor contractions, the patient was prescribed propiverine hydrochloride 15 mg four times a day. The alpha-adrenoceptor blocking drug doxazosin was used to reduce the severity of autonomic dysreflexia. Following 4 weeks of treatment with propiverine and doxazosin, the headache subsided completely. We learned from this case that bladder spasms in individuals with spinal cord injury can lead to severe, recurrent episodes of autonomic dysreflexia that, in turn, can predispose to vascular complications in the brain. Therefore, it is important to take appropriate steps to control bladder spasms and thereby prevent recurrent episodes of autonomic dysreflexia. Intermittent catheterisations along with an alpha-adrenoceptor blocking drug (doxazosin) and an antimuscarinic drug (propiverine hydrochloride) helped this individual to control autonomic dysreflexia, triggered by bladder spasms during the night.

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STUDY DESIGN: Case report. OBJECTIVES: To report insidious development of autonomic dysreflexia and hydronephrosis due to dyssynergic voiding following discontinuation of intrathecal baclofen therapy. SETTING: Regional Spinal Injuries Centre, Southport, UK. METHODS: A male patient with paraplegia at T-5 (ASIA-A) had implantation of Medtronic Synchromed 8615 s programmable pump to control intractable spasms. After 4 years, the baclofen pump needed replacement because of battery exhaustion. At this time, he was taking oxybutynin 2.5 mg twice a day. He wore a penile sheath and performed intermittent catheterisation three times a day. Intravenous urography showed no dilatation of pelvicalyceal systems or ureters. During the course of the next 4 months, the dose of baclofen had to be increased gradually to 820 microg/day in order to control the spasms. Investigations revealed disconnection of the tube from the pump. The patient decided to undergo explantation of the pump and discontinue intrathecal baclofen therapy altogether. Following removal of the pump, he was prescribed baclofen 20 mg four times a day and diazepam 5 mg twice a day. He continued penile sheath drainage with oxybutynin 2.5 mg twice a day. Although spasms were controlled with oral baclofen and diazepam, he started getting transient, mild headache during reflex voiding. After nearly 2 years, he developed unbearable and pounding headache while passing urine. RESULTS: The dose of oxybutynin was increased to modified release formulation, 20 mg, once daily. He was prescribed modified release alfuzosin 10 mg once a day. Indwelling urethral catheter drainage was instituted. Intravenous urography showed dilation of left renal pelvis and calyces, and left ureter. After a fortnight, the dose of modified release oxybutynin was increased further to 25 mg once a day. After a month, he started performing self-catheterisation every 3 h and symptoms of autonomic dysreflexia subsided completely. A follow-up intravenous urography performed 6 months later, showed normal appearances of the left kidney. CONCLUSION: Spinal cord injury patients, in whom intrathecal baclofen therapy is terminated, need close monitoring of their urological status. Medications, which are prescribed for neuropathic bladder, and the method of bladder drainage, may need suitable changes, as discontinuation of intrathecal baclofen therapy can result in reappearance of detrusor-sphincter dyssynergia in previously susceptible patients.

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BACKGROUND: The aim of this study is to evaluate the value ofTc-99 HMP AO cerebral SPECT imaging to confirm brain death in patients with complex spinal automatism. METHODS: Fifteen patients (8 female, 7 male) aged between 1,5-48 years showing spinal movements within 24-72 hours after brain death were examined with Tc-99 HMPAO cerebral SPECT. RESULTS: All patients demonstrated empty skull on Tc-99 HMPAO images and no contradictory case was ob- served between standard clinical criteria and SPECT study. CONCLUSION: Non-invasive brain SPECT study is valuable to diagnose and confirm brain death with spinal automatism in adults and children. Key words: Tc-99 HMPAO SPECT, brain death, spinal automatism

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STUDY DESIGN: Case report. OBJECTIVES: Description of a rare trigger for autonomic dysreflexia. SETTING: Princess Royal Spinal Injuries Unit, Sheffield. METHODS AND RESULTS: A case of Charcot's spine (neuropathic spinal arthropathy) in a woman with a traumatic T5 paraplegia is described. She developed symptoms of autonomic dysreflexia, brought on by changes in posture. The postural variation was attributable to a freely mobile neuropathic spondylolisthesis at the L4/5 level. A laminectomy performed for the implantation of a sacral anterior root stimulator was identified as a causative factor in the development of the neuropathic joint. Surgical stabilisation and fusion resulted in amelioration of her symptoms. CONCLUSION: Neuropathic spine is a rare cause of autonomic dysreflexia that should be considered when other more common factors have been excluded. The development of Charcot's spine in the spinal cord injured population is facilitated by surgical procedures involving the vertebrae.

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