Stroke in acute type A aortic dissection: the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD)

Abstract

OBJECTIVES Stroke is a serious complication in patients with acute type A aortic dissection (ATAAD). Previous studies investigating stroke in ATAAD patients have been limited by small cohorts and have shown diverging results. We sought to identify risk factors for stroke and to evaluate the effect of stroke on outcomes in surgical ATAAD patients. METHODS The Nordic Consortium for Acute Type A Aortic Dissection database included patients operated for ATAAD at 8 Scandinavian Hospitals between 2005 and 2014. RESULTS Stroke occurred in 177 (15.7%) out of 1128 patients. Patients with stroke presented more frequently with cerebral malperfusion (20.6% vs 6.3%, P < 0.001), syncope (30.6% vs 17.6%, P < 0.001), cardiogenic shock (33.1% vs 20.7%, P < 0.001) and pericardial tamponade (25.9% vs 14.7%, P < 0.001) and more often underwent total aortic arch replacement (10.7% vs 4.7%, P = 0.016), compared to patients without stroke. In the 86 patients presenting with cerebral malperfusion, 38.4% developed stroke. Thirty-day and 5-year mortality in patients with and without stroke were 27.1% vs 13.6% and 42.9% vs 25.6%, respectively. Stroke was an independent predictor of early- [odds ratio 2.02, 95% confidence interval (CI) 1.34–3.05; P < 0.001] and midterm mortality (hazard ratio 1.68, 95% CI 1.27–2.23; P < 0.001). CONCLUSIONS Stroke in ATAAD patients is associated with increased early- and midterm mortality. Preoperative cerebral malperfusion and impaired haemodynamics, as well as total aortic arch replacement, were more frequent among patients who developed stroke. Importantly, a large proportion of patients presenting with cerebral malperfusion did not develop a permanent stroke, indicating that signs of cerebral malperfusion should not be considered a contraindication for surgery.

Early and late outcomes of type A acute aortic dissection with common carotid artery involvement

“… 1 , 5 , 8 Postoperative cerebral malperfusion was present in 17% to 69% of patients with preoperative cerebral malperfusion, compared with 4% to 15% of those with no preoperative cerebral malperfusion. 3 , 5 , 6 , 8 , 22 , 23 , 24 Postoperative stroke was associated with significant morbidities 25 and also was a risk factor for long-term mortality, as reported by Chemtob and colleagues. 6 In the present study, the thrombosed group had more postoperative neurologic deficits and worse long-term mortality.…”

“… 3 , 5 , 6 , 8 , 22 , 23 , 24 Postoperative stroke was associated with significant morbidities 25 and also was a risk factor for long-term mortality, as reported by Chemtob and colleagues. 6 In the present study, the thrombosed group had more postoperative neurologic deficits and worse long-term mortality. Furthermore, no patients with mRS ≥5 were discharged to home.…”

“…In previous studies, 8%-18% of patients with ATAAD had preoperative cerebral malperfusion, and in-hospital mortality rates after surgery were quite high, at 26%-56%. [3][4][5][6][7][8] We have previously reported on surgical strategies. The conventional strategy reported in 2005 3 is straightforward immediate surgery to minimize the interval between onset time and a central repair.…”

“…In previous studies, 8%-18% of patients with ATAAD had preoperative cerebral malperfusion, and in-hospital mortality rates after surgery were quite high, at 26%-56%. 3 , 4 , 5 , 6 , 7 , 8…”

Time for systematic tackling the disastrous effect of stroke in type A aortic dissection surgery

“…2 In the contemporary NORCAAD study, the pre-, intra-, and postoperative possible stroke scenarios added up to an overall stroke incidence of almost 16% and the associated surgical mortality to 27%. 3 In this issue of the Journal, Fichadiya et al 4 present their basic work to improve the current understanding of precise neuroanatomical characteristics, mechanisms of injury, and clinical severity of stroke when it is detected after ATAAD surgery. They hypothetise, that attempts to reduce stroke through changes in intraoperative surgical technique will be ineffective if the etiology and pathogenesis is not fully understood.…”