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There are three cases of spontaneous ASAS presenting in the
spinal artery syndrome
peripartum period. A primigravida at 32 weeks™ gestation pre-
sented with rapid and profound paralysis.96 She had preservation Women at risk include those with scleroderma, SLE, Takayasu
of posterior column function, and negative myelograms and CT giant cell arteritis, Raynaud syndrome, and atherosclerosis.
scans. After two months she had nearly complete neurological Regional anesthesia is not contraindicated; however, avoidance
recovery. Another woman presented 20 days postpartum with of epinephrine-containing local anesthetic solutions would seem
similar sudden onset of cervicothoracic pain followed by para- prudent. In addition, maintaining a normal mean arterial pres-
plegia.253 She remained paraplegic. Neither patient had risk fac- sure for the duration of the regional technique is appropriate. For
tors other than the hypercoagulability of pregnancy, and neither C/S in a woman with an in-situ labor epidural, bupivacaine rather
had received a regional anesthetic. Unfortunately, arteriograms than lidocaine with epinephrine would be reasonable. However,
were not done, therefore any intrinsic abnormalities of spinal the risk of ASAS in this group must be extremely low and available
cord arterial supply are unknown. The third case is a woman information suggests that a necessary cofactor such as preexist-
who, seven days after an uncomplicated labor epidural, devel- ing vascular disease or vascular malformation must be present.
oped classic ASAS.245 Investigations included a CT scan, myelo- Effective management of ASAS emphasizes early diagnosis and
gram and EMG, which led to the diagnosis of ASAS. She had treatment of any correctable factors. Pregnancy may cause
normal coagulation status at the time of delivery. increased susceptibility to impairment of spinal cord blood flow
The addition of vasoconstrictors, such as epinephrine, to local due to engorged venous plexi, which become more engorged
anesthetic solutions for major regional anesthesia is postulated to during second stage pushing. Catheter-induced vasospasm may
cause vasoconstriction of the anterior spinal artery resulting in present with a clinical picture similar to ASAS and should be
ASAS.254,255 There are 11 cases of paraplegia following epidural considered in the differential diagnosis. Appropriate manage-
anesthesia attributed to the use of epinephrine.256 However, dog ment includes immediate withdrawal of the epidural catheter
studies have demonstrated that clinically relevant concentrations and neurological evaluation.
of epinephrine in the epidural space do not cause sufficient
impairment of spinal cord blood flow to result in ASAS.107,257
Summary
In the presence of preexisting disease of the spinal arteries, or
periods of significant hypotension, epinephrine in the epidural Diseases of the spinal cord in women in the childbearing years
space may cause sufficient vasoconstriction of the anterior spinal range from the very rare to the merely uncommon. Today, medi-
artery to impair blood flow and cause ASAS.107,256 There is one cally challenged patients are encouraged to integrate fully into
case report of ASAS in a parturient who received a labor epidural society including the role of motherhood. For this reason, greater
infusion containing bupivacaine with 1:400 000 epinephrine.258 numbers of cord compromised patients will present for obstetrical
Less than two hours after the infusion had been initiated, a C/S anesthesia care in the future. Appropriate management decisions
was required for fetal reasons. In the operating room, the woman are based on an appreciation of the disease processes as well
was hypotensive for a short period (BP decreased from 110 to as the interaction between these processes and pregnancy. The



209
3 Nervous system disorders


challenge is to achieve outcomes in these patients comparable to 27. Gandevia, S. C. Does the diaphragm fatigue during parturition? Lancet 1993;
341: 347“8.
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29. Roberts, A. G., Graves, C. R., Konrad, P. E. et al. Intrathecal baclofen pump
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