Is surgery in acute aortic dissection type A still contraindicated in the presence of preoperative neurological symptoms?

Most, Henriette; Reinhard, Brigitta; Gahl, Brigitta; Englberger, Lars; Kadner, Alexander; Weber, Alberto; Schmidli, Jürg; Carrel, Thierry; Huber, Christoph

doi:10.1093/ejcts/ezu538

Cited by 28 publications

(14 citation statements)

References 26 publications

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“…In a recent cohort study of 53 Stanford classification type A acute aortic dissection patients with preoperative neurological deficits, half of the patients completely recovered from focal neurological deficits after aortic surgery. 18 Interestingly, preoperative GCS did not adequately predict neurological recovery; the proportion of patients with preoperative GCS 8 was 20% in those who fully recovered and 37% in those with persistent deficits. Surgery within 5 h after onset of symptoms increases the likelihood of favourable outcome in patients who present with coma.…”

Section: Discussionmentioning

confidence: 91%

“…Surgeons often weigh the presence of neurological manifestations in their decision whether to perform surgery. 18 Before and during surgery, a low blood pressure is maintained for several hours, which is necessary to prevent aortic rupture, but unfavourable in the presence of brain ischaemia. Prolonged hypotension may induce negative effects on the penumbra, increasing the risk for expansion of the infarct.…”

Section: Discussionmentioning

confidence: 99%

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Aortic dissection masquerading as a code stroke: A single-centre cohort study

Guglielmi

Groeneveld

Posthuma

et al. 2019

European Stroke Journal

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Introduction: Data on the incidence of acute aortic dissection in the code stroke population are scarce. We report estimated incidence, clinical manifestations, treatment and outcomes of patients with an acute aortic dissection in a code stroke cohort from a comprehensive stroke centre. Patients and methods: We used data from a single-centre prospective registry of consecutive adult patients who presented to the emergency department between 2015 and 2018 with neurological deficits suggestive of an acute stroke ('code stroke'). All patients routinely underwent non-contrast computed tomography of the brain and computed tomography-angiography of the aortic arch, cervical and intracranial arteries. Results: Of 2874 code stroke patients, 1563 (54.4%) had acute ischaemia (ischaemic stroke or transient ischaemic attack). Fifteen patients (0.5% of code stroke patients and 0.8% of patients with acute ischaemia) had an acute aortic dissection (all Stanford classification type A). Discerning clinical manifestations were decreased consciousness in 11/15 (73%), pain in 8/15 (53%) and low systolic blood pressure (mean 106 mmHg, SD30). Acute aortic dissection was an incidental finding during computed tomography-angiography in 4/15 (27%). Two out of 15 patients (13%) received intravenous thrombolysis, 9/15 (60%) underwent aortic surgery and 10/15 (67%) died. Of those who survived, 3/5 (60%) had a good functional outcome (modified Rankin Scale 0-2). Discussion and Conclusion: In our comprehensive stroke centre, about 1/200 code stroke patients and 1/125 patients with acute ischaemia had an acute aortic dissection. Multicentre studies are necessary to acquire a more reliable estimate of the incidence of acute aortic dissection in the code stroke population. Given the ramifications of missing this diagnosis, imaging of the entire aortic arch is important in these patients.

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Section: Discussionmentioning

confidence: 91%

Section: Discussionmentioning

confidence: 99%

Aortic dissection masquerading as a code stroke: A single-centre cohort study

Guglielmi

Groeneveld

Posthuma

et al. 2019

European Stroke Journal

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“…18) In patients for whom we did not indicate surgery due to consciousness disorder, the mortality rate was 89%; we cannot rule out the presence of patients in whom survival may have been achieved by positive surgery. In the future, indication criteria for surgery should be reviewed.…”

Section: Disclosure Statementmentioning

confidence: 81%

Pathophysiology and Surgical Treatment of Type A Acute Aortic Dissection

Uchida

Karube

Yasuda

et al. 2016

Annals of Vascular Diseases

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This is a translation of Jpn J Vasc Surg 2015; 24: 127-134. Objectives: We report the pathophysiology and treatment results of type A acute aortic dissection from our 20-year experience. Methods: We studied 673 patients with type A acute aortic dissection who underwent initial treatment from 1994 through July 2014. We divided these patients into two groups. The former group comprised 448 patients from 1994 through 2008, and the latter group comprised 225 patients from 2009 onward, when the current strategy of initial treatment and surgical technique including the early organ reperfusion therapies were established. Results: Women were significantly often presented than men in patients over 60 years of age. Thrombosed-type dissection accounted for more than half in patients over 70 years, and significantly often complicated pericardial effusion and cardiac tamponade than patent type. Malperfusion occurred in 26% of patients. Central repair operations were performed in 579 patients. In-hospital mortality for all patients was 15%, and for the patients who underwent central repair operations was 10%. Former period of operation, malperfusion, and preoperative cardiopulmonary arrest were significant risk factor of in-hospital death. Preoperative left main trunk (LMT) stents were placed in eight patients and superior mesenteric artery (SMA) intervention was performed in five, they were effective to improve the outcome. From 2009 onward, in-hospital mortality was 5.0% and there was no significant risk factor. Conclusion: Surgical results of type A acute aortic dissection were dramatically improved in the past 20 years. Early reperfusion strategy for the patients with malperfusion improved the outcomes. (This article is a translation of Jpn J

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“…Cerebral protection, which includes cannulation of the right axillary artery, ACP, and measurement of cerebral oximetry during operation, was applied in most of the analogous studies [18].…”

Section: Discussionmentioning

confidence: 99%

Risk factors for neurological dysfunctions after surgical repair of acute aortic dissection type A

Zdravković¹,

Nesic²,

Živković³

et al. 2020

kitp

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Introduction: Technical improvement and new operative strategies significantly influence survival and outcomes after the treatment of acute aortic dissection type A (AADA). However, postoperative complications and particularly neurological dysfunctions (ND) are still very common. Aim: To identify preoperative and intraoperative factors as well as immediate postoperative conditions with an influence on the occurrence of neurological complications of surgical treatment of AADA and accordingly take action to reduce them. Material and methods: Between January 2013 and December 2018, 240 patients with AADA were emergently surgically treated. All patients were divided into two groups: group I-patients with postoperative ND (subgroup Ia-patients with mild, transient ND and Ib-patients with severe ND) and group II-patients without ND. Results: Neurological damage after the operation was registered in 87 (39.5%) patients. Thirty (13.6%) patients had mild ND and 57 (25.9%) severe. Presence of preoperative neurological deficit, reduced level of consciousness, supra-aortic vessel dissection, hemodynamic instability, and excessive postoperative bleeding with hypotension are factors with a highly statistically significant association with the occurrence of severe ND. Neurological complications were not identified in 66.7% of patients who were axillary cannulated versus 55.9% of patients cannulated in the other way but the difference did not reach statistical significance (p = 0.1099). Conclusions: Advanced neuroprotective strategies during surgical treatment of AADA are associated with favorable neurological outcomes, especially in a group of patients with identified risk factors for ND.

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Is surgery in acute aortic dissection type A still contraindicated in the presence of preoperative neurological symptoms?

Abstract: More than half of our patients recovered completely from ND due to AADA after surgery. Severity of clinical symptoms had a predictive value. Patients suffering from AADA and presenting with ND before surgery should not be excluded from emergency surgery.

Cited by 28 publications

References 26 publications

Aortic dissection masquerading as a code stroke: A single-centre cohort study

Aortic dissection masquerading as a code stroke: A single-centre cohort study

Pathophysiology and Surgical Treatment of Type A Acute Aortic Dissection

Risk factors for neurological dysfunctions after surgical repair of acute aortic dissection type A

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