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J Thorac Cardiovasc Surg 2001;122:1019-1020
© 2001 The American Association for Thoracic Surgery
Brief Communications |
From the Department of Cardiovascular Surgery, Hokkaido University School of Medicine, Sapporo, Japan.
Received for publication Nov 2, 2000. Accepted for publication Feb 12, 2001. Address for reprints: Takashi Kunihara, MD, Department of Cardiovascular Surgery, Hokkaido University School of Medicine, N14, W5, Kita-ku, Sapporo, Japan 060-8648 (E-mail: kunihara{at}med.hokudai.ac.jp).
See related editorial on page 853.
S100ß protein, which is found at a high concentration in glial and Schwann cells, is considered to be a promising biochemical marker of spinal cord injury (SCI).
1 However, serum S100ß levels after cardiopulmonary bypass (CPB) are influenced by extracerebral contamination, 2 increased permeability of the blood-brain barrier, and impaired renal function. 3 Because S100ß levels in the cerebrospinal fluid (CSF) are unlikely to be affected by these responses to CPB, and CSF samples can be collected when CSF drainage is used, it seems reasonable to measure them as a marker of SCI. The purpose of this study is to elucidate the alterations of S100ß levels in the CSF and the serum up to 72 hours postoperatively and to correlate them with the neurologic outcome in patients undergoing thoracoabdominal aortic operations.
Methods
A total of 23 patients (12 men and 11 women; mean age, 64 ± 14 years) undergoing prosthetic replacement of the descending thoracic (n = 6) or thoracoabdominal aorta (n = 17) and CSF drainage between April 1997 and February 2000 were enrolled in this study. The medical ethical committee approved CSF drainage, and all patients gave written informed consent. Patients with postoperative renal insufficiency were excluded. The cause of disease was dissection in 8 patients and nondissection degenerative disease in 15 patients. Two patients underwent nonelective operations.
Partial femorofemoral CPB was used in 18 patients who were divided into 2 groups with (SCI group, n = 4) or without (FF group, n = 14) postoperative SCI. Deep hypothermic total CPB was used in 5 patients (DH group). The lowest rectal temperature for each adjunct was 34°C ± 1°C and 20°C ± 2°C. Characteristics of each group were comparable, except that patients with dissection were more prevalent (P = .0321) and duration of CPB was significantly longer (P = .0024) in the DH group. A cardiotomy sucker was used in all but 4 patients in the FF group. A centrifugal cell-salvage device was used in all patients, and an arterial filter was not used.
CSF drainage was started just after the induction of anesthesia and was continued until 72 hours after the operation. CSF was allowed to freely drain if CSF pressure exceeded 13 cm H2O. The CSF and arterial blood were collected at just before the operation and at 0, 6, 12, 18, 24, 48, and 72 hours after the operation. S100ß levels were measured with an immunoradiometric assay kit (Sangtec Medical, Bromma, Sweden). The minimum detectable level was 0.2 µg/L. All values are expressed as means ± standard deviation.
Results
There were no hospital deaths. Postoperative SCI occurred in 4 patients (2 with paraplegia and 2 with paraparesis) with nondissecting degenerative aneurysms.
CSF S100ß levels in the SCI group showed a dramatic increase from 6 hours after the operation compared with the other 2 groups (P < .0001 vs FF group and P < .01 vs DH group by repeated-measures analysis of variance) and reached their peak at 48 postoperative hours (289 ± 454 µg/L, Figure 1). From 18 to 72 hours postoperatively, both paraplegic patients had higher CSF S100ß levels than patients with paraparesis.
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Mean serum S100ß levels were less than 1.5 µg/L and reached their peak just after the operation in each group (Figure 2). In the SCI group serum S100ß levels showed a second and more pronounced peak at 24 hours postoperatively (1.3 ± 1.4 µg/L).
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Although we used only a small cohort, results of the present study clearly demonstrated that CSF S100ß levels were significantly correlated with SCI, and those in the SCI group peaked 48 hours after thoracoabdominal aortic operations. Another important finding is that CSF levels seem more reliable than serum levels because CSF S100ß levels of the SCI group were from 10- to 100-fold higher than serum S100ß levels. These results not only confirmed those of a previous report by Van Dongen and colleagues 1 but also disclosed alterations of CSF S100ß levels after 24 postoperative hours with the addition of statistical power. Although we could treat potential SCI with a novel rapid assay, 4 the value of CSF S100ß levels to predict SCI earlier than clinical diagnosis remains to be investigated in the further study. Higher CSF S100ß levels in the DH group may indicate more pronounced inflammatory response related to CPB and reduced collateral circulation of the spinal cord during open distal anastomosis. Larger studies will be required to confirm this finding. In addition to augmentation of spinal cord perfusion pressure, removal of S100ß from the CSF may be another possible advantage of prolonged CSF drainage to prevent delayed aggravation of SCI because S100ß may induce apoptotic neuronal death in high concentrations. 5 In conclusion, CSF S100ß level seem to be a sensitive biochemical marker of SCI.
Acknowledgments
We thank Toshiyuki Onishi, MD, Central Institute of Radioisotope Science, and Kenji Fujieda, MD, Department of Pediatrics, for help in measurement of S100ß levels.
References
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