Case report
A patient in her late seventies was incidentally found to have a large
infrarenal abdominal aortic aneurysm in 2013 for which she had undergone
an uneventful percutaneous endovascular aortic repair with left chimney.
She lived alone, remained independent in her activities of daily living
and was community ambulant without aid.
She was electively admitted in September 2019 for embolization of a type
2 endoleak by the interventional radiologist. Super selective
cannulation of the distal aspect of the iliolumbar branch supplying the
nidus with a micro catheter was performed. Embolization was carried out
using Onyx® until complete exclusion of the nidus.
This was followed by repeat aortogram which showed complete exclusion of
the nidus from right-sided branches. However, there was continued
filling of the nidus from the left lumbar branches. It was therefore
decided to embolise the left side. Post embolization, angiogram showed
complete exclusion of the endoleak and the left sided branches supplying
the endo leak.
Five hours after the procedure the patient complained of bilateral lower
limb weakness and numbness, right more than left. Physical examination
revealed lower motor neurone pattern of weakness over bilateral lower
limbs, right worse than left (Table 1). Sensation testing revealed
normal sensation over left, impaired sensation for right L2 to S1.
Proprioception at bilateral big toes were intact. Reflexes were absent
in bilateral lower limbs.
Lumbar spinal drain was inserted to decompress the spinal cord to allow
more arterial flowas there was concern with spinal cord ischaemia. The
patient was started on fluid replacement to maintain the mean arterial
pressure above 80mmHg. Urgent CT aortogram followed by MRI thoracolumbar
spine were performed. Aortogram showed post interval embolization of
bilateral feeding arteries. Onyx material was seen within a branch of
the embolised right iliolumbar artery which extends into the spinal
canal at the level of L3 and appears to exit at the level of L2. It ran
external to the thecal sac. MRI thoracolumbosacral spine showed no
abnormal cord signal or restricted diffusion.
She was subsequently admitted for inpatient multidisciplinary
rehabilitation. On initial functional assessment, she required moderate
assistance for bed mobility and transfer with poor dynamic sitting and
standing balance. She did not complain of pain. After 1 month of
inpatient rehabilitation, she made some neurological recovery with
functional improvement. She had good dynamic sitting balance and was
able to transfer under supervision. She can self-propel wheelchair
within the ward. However she had poor standing balance and was still
unable to ambulate. She was discharged to a sub-acute rehabilitation
facility before being discharged home. Please see her functional
improvement over time using the Functional Independence Measure (FIM)
instrument illustrated in table 1.
Electrophysiology study was performed 12 weeks later showed
electrophysiological evidence of an acute right lumbar plexopathy
involving the right obturator and femoral nerves, with no evidence of
axonal continuity.
She was reviewed in the outpatient clinic 14 weeks later. Neurologically
remained largely unchanged for right lower limb, however left lower limb
power had further improved to about 4 on manual motor testing.
Functionally she had also made slight progression, she was able to walk
25 metres using walking frame with 1 person providing standby assist.
However she was still dependent on wheelchair for longer distance
ambulation.