title: Lack of neurologic improvement after aortic repair for acute type A aortic dissection complicated by cerebral malperfusion: predictors and association with survival.
abstract: BACKGROUND
  Surgical treatment of acute type A aortic dissection complicated by cerebral malperfusion remains challenging. This study evaluated predictors of lack of neurologic improvement after aortic repair for acute type A dissection complicated by cerebral malperfusion and assessed relationship with survival.
  
  
  METHODS
  We retrospectively reviewed 41 consecutive patients operated on between 1999 and 2008 for acute type A dissection complicated by cerebral malperfusion. Lack of postoperative neurologic improvement was defined as a difference between baseline and postoperative National Institutes of Health Stroke Scale scores of 3 points or less.
  
  
  RESULTS
  Lack of neurologic improvement was seen in 15 patients (37%). Logistic regression analysis, baseline National Institutes of Health Stroke Scale score (odds ratio, 6.7; 95% confidence interval, 1.4-32.4; P = .02), and time to surgery (odds ratio, 14.6; 95% confidence interval, 2.7-8.5; P = .002) were significantly associated with lack of neurologic improvement. In receiver operating characteristic analysis, National Institutes of Health Stroke Scale score greater than 11 and time to surgery longer than 9.1 hours were best cutoffs for predicting lack of neurologic improvement. Thirty-day mortality was 14.6%. All early deaths were caused by large hemispheric infarction. Postoperative computed tomography or magnetic resonance imaging revealed cerebral infarction in 21 patients (51%). Five-year survival was significantly lower in patients without neurologic improvement (33% ± 12% vs 84% ± 7%, log-rank P <.001).
  
  
  CONCLUSIONS
  Time to surgery and baseline National Institutes of Health Stroke Scale score were predictors of lack of improvement, which was associated with poor survival.
authors.affiliation: Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan. naotofrcs@gmail.com
authors.forename: Naoto
authors.initials: N
authors.lastname: Morimoto
authors.forename: Kenji
authors.initials: K
authors.lastname: Okada
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Okita
mesh_terms: D000208:Acute Disease; D000368:Aged; D000784:Aortic Dissection / Q000150:complications / Q000503:physiopathology* / Q000601:surgery*; D001014:Aortic Aneurysm / Q000150:complications / Q000503:physiopathology* / Q000601:surgery*; D002339:Carotid Arteries / Q000000981:diagnostic imaging; D002544:Cerebral Infarction / Q000209:etiology / Q000401:mortality; D002560:Cerebrovascular Circulation; D005260:Female; D006801:Humans; D008297:Male; D011379:Prognosis; D020521:Stroke / Q000150:complications*; D018608:Ultrasonography, Doppler