You’re caring for patients in the PACU and you’re called because a patient who has just undergone elective laparoscopic cholecystectomy to treat symptomatic cholelithiasis is suddenly paraplegic. What is the differential diagnosis? What should you do? Drs. Robert L. Mcclain and Sher-Lu Pai, Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, describe a patient such as this in their case report “Acute Aortic Occlusion Presenting as Paraplegia: A Catastrophic Complication in an Elective Surgical Patient” that was published in the 15 November 2013 issue of A&A Case Reports.
The etiology of acute paraplegia may be from neurologic or vascular calamity. Regardless of the reason, an assessment must be made immediately. In the PACU, this patient had intense lower back pain as well as numbness and severe weakness in both legs. On exam, there was no discrete dermatome level for her sensory deficit and there was no point tenderness along the spine.
The patient was sent for acute magnetic resonance imaging. The MRI showed no deficit. The patient was subsequently sent for computed tomographic arteriogram, which showed thrombus within the infrarenal aorta with a segment of marked narrowing and extension of the thrombus to the popliteal arteries bilaterally.
The patient was acutely treated in interventional radiology with catheter-directed alteplase infusion therapy to the thrombosed vessels. Twelve hours later thrombosis was still seen in the popliteal arteries. The patient continued to deteriorate and died 44 hours after surgery.
Acute aortic occlusion is rare and most patients with this diagnosis have not undergone surgery. Thrombosis can occur in situ, though clots can also embolize from the heart. Hypercoagulability is seen in patients with cancer, although this patient had breast cancer in the distant past. Abdominal insufflation in this patient may have contributed to this patient’s thrombosis. It is also possible that an aortic atherosclerotic plaque may have been dislodged or disrupted from the surgical manipulation. An autopsy was not performed, so the etiology will never be known.
As an aside, the use of autopsies has fallen steeply. A recent article showed as many as one quarter of autopsies can reveal significant disease that was unknown to the clinician despite the availability of modern analysis. Perhaps we could have been learned how to prevent this complication if the etiology could have been determined following death.