Selective cerebral perfusion at 28 °C - is the spinal cord safe?

Objective: To shorten cooling/rewarming associated with hypothermic neuroprotection strategies during complex aortic arch surgery, selective cerebral perfusion (SCP) at 28 °C has recently been advocated, although its safe limits - especially with regard to the ischaemic tolerance of the spinal cord - have not been systematically examined. Methods: Twenty juvenile Yorkshire pigs (30.3 ± 2.8 kg) were randomly allocated to undergo circulatory arrest and SCP at 28 °C for 90 min (group A; N = 12) or 120 min (group B; N = 8) at 50 mmHg using alpha-stat pH management. Spinal cord blood flow (SCBF) was assessed using fluorescent microspheres at baseline (prior to SCP); at 5 and 80 min during SCP, and at 1, 5 and 48 h after cardiopulmonary bypass (CPB). A modified Tarlov score was used to evaluate neurobehavioural recovery in all survivors blindly from videotapes for 5 days postoperatively. Histological ischaemic spinal cord injury was scored after sacrifice. Results: All pigs could be weaned from CPB and ventilation, but seven pigs (58%) in group A and five (63%) in group B developed multi-organ failure and died within 24 h. SCBF diminished immediately after initiation of SCP and was absent throughout SCP in all segments below T8/9, recovering to baseline 1 h after SCP at all cord levels. All survivors suffered moderate-to-severe histological lumbar spinal cord damage, more severe in group B (p ≤ 0.049). Three of five group A pigs recovered normal function, but two suffered paraparesis. Group B survivors had a worse neurologic outcome (p <0.0001): all suffered paraplegia (one immediate, and two on day 2, after initial recovery). Conclusion: SCP provides insufficient SCBF below T8/9 to sustain cord viability. At 28 °C, the ischaemic tolerance of the cord may be exceeded enough by 90 min to impair function; by 120 min, SCP at 28 °C invariably results in paraplegia.