title: Patients with type A acute aortic dissection presenting with major brain injury: should we operate on them?
abstract: OBJECTIVE
  The management strategy remains controversial for patients presenting with type A acute aortic dissection with cerebrovascular accident or coma. The present study aimed to help guide surgeons treating these high-risk patients.
  
  
  METHODS
  Of 1873 patients with type A acute aortic dissection enrolled in the International Registry for Acute Dissection, 87 (4.7%) presented with cerebrovascular accident and 54 (2.9%) with coma. The hospital and 5-year results were stratified by the presence and type of brain injury (no injury vs stroke vs coma) and management type (medical vs surgical). Independent predictors of short- and mid-term survival were identified.
  
  
  RESULTS
  Presentation with shock, hypotension, or tamponade (46.8% vs 25.2%; P < .001) and arch vessel involvement (55.0% vs 36.1%; P < .001) was more likely in patients with brain injury. Surgical management was avoided more often in patients with coma (33.3%) or cerebrovascular accident (24.1%) than in those without brain injury (11.1%; P < .001). The overall hospital mortality was 22.7% without brain injury, 40.2% with cerebrovascular accident, and 63.0% with coma (P < .001). Mortality varied among the management types for both cerebrovascular accident (76.2% medical vs 27.0% surgical; P < .001) and coma (100% medical vs 44.4% surgical; P < .001). Postoperatively, cerebrovascular accident and coma resolved in 84.3% and 78.8% of cases, respectively. On logistic regression analysis, surgery was protective against mortality in patients presenting with brain injury (odds ratio 0.058; P < .001). The 5-year survival of patients presenting with cerebrovascular accident and coma was 23.8% and 0% after medical management versus 67.1% and 57.1% after surgery (log rank, P < .001), respectively.
  
  
  CONCLUSIONS
  Brain injury at presentation adversely affects hospital survival of patients with type A acute aortic dissection. In the present observational study, the patients selected to undergo surgery demonstrated improved late survival and frequent reversal of neurologic deficits.
authors: Department of Cardiac Surgery, S Orsola-Malpighi Hospital, Bologna, Italy. marco.dieusanio2@unibo.it
authors: Marco
authors: M
authors: Di Eusanio
authors: Himanshu J
authors: HJ
authors: Patel
authors: Christoph A
authors: CA
authors: Nienaber
authors: Daniel M
authors: DM
authors: Montgomery
authors: Amit
authors: A
authors: Korach
authors: Thoralf M
authors: TM
authors: Sundt
authors: Carlo
authors: C
authors: Devincentiis
authors: Matthias
authors: M
authors: Voehringer
authors: Mark D
authors: MD
authors: Peterson
authors: Truls
authors: T
authors: Myrmel
authors: Gianluca
authors: G
authors: Folesani
authors: Magnus
authors: M
authors: Larsen
authors: Nimesh D
authors: ND
authors: Desai
authors: Joseph E
authors: JE
authors: Bavaria
authors: Jehangir J
authors: JJ
authors: Appoo
authors: Teresa M
authors: TM
authors: Kieser
authors: Rossella
authors: R
authors: Fattori
authors: Kim
authors: K
authors: Eagle
authors: Roberto
authors: R
authors: Di Bartolomeo
authors: Santi
authors: S
authors: Trimarchi
mesh_terms: D000208:Acute Disease; D000368:Aged; D000784:Aortic Dissection / Q000150:complications / Q000401:mortality / Q000601:surgery*; D001014:Aortic Aneurysm / Q000150:complications / Q000401:mortality / Q000601:surgery*; D001930:Brain Injuries / Q000150:complications* / Q000401:mortality; D002170:Canada; D003128:Coma / Q000150:complications* / Q000401:mortality; D005060:Europe; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007557:Israel; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000150:complications* / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality