title: Acute type A aortic dissection complicated by stroke: can immediate repair be performed safely?
abstract: OBJECTIVE
  Emergency surgical intervention for acute type A aortic dissection complicated by stroke remains controversial. The urgency of immediate repair in this setting is tempered by the concern that cerebral reperfusion may worsen neurologic outcome. The purpose of this study was to report and analyze our results with acute type A aortic dissection complicated by stroke.
  
  
  METHODS
  Between September 1999 and March 2005, 151 consecutive patients presented with acute type A aortic dissection. Of this group, 16 (10.6%) patients had sustained a preoperative stroke. Mean age was 56 years (range 43-73 years), with 6 (38%) women. Right hemispheric, left hemispheric, and bilateral strokes occurred in 81%, 13%, and 6%, respectively. Computed tomographic scan or transesophageal echocardiography diagnosed aortic dissection; clinical examination, computed tomographic scan, or transcranial Doppler ultrasound diagnosed stroke. Aortic repair was performed with cardiopulmonary bypass, profound hypothermic circulatory arrest, and retrograde cerebral perfusion. One patient with complete neurologic devastation (coma) was not operated on.
  
  
  RESULTS
  Overall hospital mortality was 18.8% (3/16). Mortality in 2 patients who did not undergo surgery (1 patient who was neurologically devastated, and 1 patient whose aorta ruptured while awaiting surgery) was 100% (2/2). Operative mortality was 7% (1/14). Among patients undergoing surgery, neurologic status completely recovered in 2 (14%) patients, improved in 6 (43%) patients, remained the same in 6 (43%) patients, and worsened in none. Median time from onset of stroke to surgery was 9 hours (range 1-240 hours). Eighty percent of patients who underwent surgical repair within 10 hours had improvement in neurologic status, where as none operated on beyond 10 hours improved (P < .02).
  
  
  CONCLUSIONS
  In our experience, surgical repair of acute type A aortic dissection can be performed in the setting of preoperative stroke with acceptable mortality. Moreover, no worsening of neurologic condition was observed after surgical repair. Immediate surgical repair is warranted even if acute type A aortic dissection is complicated by stroke.
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, The University of Texas-Houston Medical School, Memorial Hermann Heart and Vascular Institute, Houston, Tex 77030, USA. Anthony.l.estrera@uth.tmc.edu
authors.forename: Anthony L
authors.initials: AL
authors.lastname: Estrera
authors.forename: Zsolt
authors.initials: Z
authors.lastname: Garami
authors.forename: Charles C
authors.initials: CC
authors.lastname: Miller
authors.forename: Eyal E
authors.initials: EE
authors.lastname: Porat
authors.forename: Paul E
authors.initials: PE
authors.lastname: Achouh
authors.forename: Jayesh
authors.initials: J
authors.lastname: Dhareshwar
authors.forename: Riad
authors.initials: R
authors.lastname: Meada
authors.forename: Ali
authors.initials: A
authors.lastname: Azizzadeh
authors.forename: Hazim J
authors.initials: HJ
authors.lastname: Safi
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000145:classification / Q000150:complications* / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000145:classification / Q000150:complications* / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D020521:Stroke / Q000150:complications*; D013997:Time Factors